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Esophageal Dysmotility
Aka: Esophageal Dysmotility, Esophageal Motility Disorder
- See Also
- Dysphagia
- Dysphagia from Esophageal Cause
- Physiology
- Swallowing (deglutition) is started
- Upper esophageal sphincter relaxes, then 2 seconds later, lower esophageal sphincter relaxes
- Food bolus passes from oropharynx into upper esophagus
- Esophageal peristalsis carries food bolus from throat to Stomach
- Contraction of one esophageal segment via excitatory Neurons
- Relaxation of next esophageal segment below the contracting segment via inhibitory Neurons
- Types: Esophageal Dysmotility
- Decreased or inactive esophageal contractility (<5% of referred cases)
- Esophageal Achalasia
- Achalasia is the most important and potentially most severe of the Esophageal Dysmotility disorders
- Increased esophageal contractility (<5% of referred cases)
- Esophageal Spasm
- Hypercontractile Esophagus ("Jackhammer Esophagus")
- Functional Esophageal Disorders (<30% of referred cases)
- Analogous to Irritable Bowel Syndrome and Functional Dyspepsia
- As with Esophageal Spasm, may present with Chest Pain, heart burn or Dysphagia
- May also have increased hypercontractility on manometry
- Benign course that is self limited
- May respond to non-pharmacologic strategies employed in other functional disorders
- Gastroesophageal Reflux Disease (55% of referred cases)
- Eosinophilic Esophagitis (8% of referred cases)
- Opioid-Induced Esophageal Dysmotility
- May present in similar fashion to other Esophageal Dysmotility disorders
- Symptoms: Esophageal Dysphagia
- Sensation of food becoming stuck in the throat, neck or chest
- Perceived location of stuck food does not correlate with the actual location of obstruction
- Palliative Factors
- Patients may attempt to relieve obstruction with standing and walking
- Provocative Factors
- Emotional stress or anxiety
- Alcohol
- Rapid eating
- Associated Symptoms
- Regurgitation of food may occur several hours after a meal
- Solid AND liquid Dysphagia is more suggestive of dysmotility
- Chest Pain
- Chest Pain associated with meals may occur with Esophageal Dysmotility
- Chest Pain unrelated to meals is more likely to be a functional esophageal disorder or esophageal reflux
- Differential Diagnosis
- See Dysphagia
- See Dysphagia from Esophageal Cause
- See Dysphagia from Oropharyngeal Cause
- Evaluation
- Step 1: Optimize Gastroesophageal Reflux Management
- Maximize acid suppression (e.g. Proton Pump Inhibitor)
- Optimize Non-Medication GERD Management
- Non-caffeinated fluid daily (e.g. 64 oz)
- Decrease Caffeine, Alcohol and provocative foods
- Tobacco Cessation and Alcohol cessation
- No food 2 hours before lying supine
- Elevate head of bed
- Step 2: Decrease or eliminate Opioids
- Opioid-Induced Esophageal Dysmotility is increasing in Incidence
- Step 3: Consider functional esophageal disorders (nearly as common as GERD)
- Strategies address modulating esophageal hypersenstivity and hypervigilence
- Stress reduction and relaxation
- Consider Cognitive Behavioral Therapy
- Antidepressants
- Step 4: Upper Endoscopy
- Indicated in all patients with Dysphagia (see red flags in GERD)
- Evaluate for malignancy and Barrett's Esophagus
- Identify structural lesions (e.g. Esophageal Stricture)
- Consider obtaining Upper GI Swallow (esophagram with barium)
- Identify inflammatory causes
- Eosinophilic Esophagitis
- Infections (e.g. candida Esophagitis)
- Achalasia findings
- Food retained in esophagus
- Increased resistance across esophagogastric junction
- Step 5: Esophageal Manometry (high resolution)
- Indications
- Dysphagia (esp. liquid) and Chest Pain refractory to maximal medical therapy
- Achalasia suspected
- Endoscopy without other cause identified
- Technique
- Performed with Nasogastric Tube with closely positioned pressure sensors
- Esophageal pressures are measured as the patient swallows various foods and liquids
- Lower esophageal sphincter pressure is also measured before swallowing and during relaxation
- Management
- Do no harm
- Functional disorders and Hypercontractile Esophagus improve or resolve spontaneously in a majority of patients
- GERD Management and functional techniques, with reassurance is effective in most cases
- Achalasia, however, is an important diagnosis with available definitive therapy
- General Measures
- See Step 1-3 in Evaluation as above
- Optimize GERD Management
- Discontinue Opioids
- Stress management, consider Antidepressants and consider Cognitive Behavioral Therapy
- Mindful eating
- Eat smaller, more frequent meals
- Eat slowly
- Choose softer foods
- Avoid foods and situations that trigger symptoms
- Hypermotility
- Precautions
- These medications decrease lower esophageal sphincter pressure and may worsen GERD
- Smooth muscle relaxants are best limited to hypermotility confirmed by manometry
- Agents
- Calcium Channel Blockers
- Nitrates (Nitroglycerin)
- Phosphodiesterase-5 Inhibitors (release nitric oxide)
- Other agents which are safe and may be effective
- Peppermint Oil (2 mints sublingual before each meal)
- Achalasia
- Myotomy (definitive therapy)
- Laparoscopic Heller Myotomy
- Incises muscles of the distal esophagus, lower esophageal sphincter and gastric cardia
- Peroral Endoscopic Myotomy
- Newer, more technically challenging, but less invasive procedure than the laparoscopic Heller myotomy
- Incises the same muscles as the Heller procedure
- Pneumatic dilation (by endoscopy)
- Disrupts lower esophageal sphincter
- Not as effective or longlasting as myotomy (dilation may need to be repeated)
- Onabotulinumtoxin A
- Endoscopic injection into lower esophageal sphincter
- Unknown efficacy, but may be used in patients at too high risk for surgery
- References
- Wilkinson (2020) Am Fam Physician 102(5):291-6 [PubMed]