Overview

An esophageal motility disorder (EMD) is any medical disorder causing difficulty in swallowing, regurgitation of food and a spasm-type pain which can be brought on by an allergic reaction to certain foods. The most prominent one is dysphagia.

Symptoms

Symptoms of esophageal dysmotility can include:

Causes

Esophageal dysmotility can be due to:

  1. An ulcer, stricture, irritation, infection, inflammation, or cancer of the esophagus.
  2. Uncoordinated or abnormal muscles of the mouth, throat, or esophagus
  3. A brain or nerve problem (such as a stroke) that weakens the muscles of the mouth, tongue, or throat (or changes their coordination)

Types

Treatment

Pharmacology – Drugs play a minimal role in the treatment of achalasia. As in DES and NE, nitrates and calcium channel blockers are of limited use and side effects are common; however, these agents can lower the pressure of the LES. Some patients report improvement with sublingual forms of nifedipine or nitrates. 7 Botulinum toxin, injected directly into the SLE under endoscopic control, has been shown to significantly reduce the pressure of the SLE in humans and animals.8 The duration of the effect of the Botulinum toxin varies, and many patients receive repeated injections as needed. These repeated injections can scar the LES and complicate a future myotomy.9 Botulinum toxin should preferably be used in frail and elderly patients, as they tend to have a prolonged response and surgery can be avoided.1

Dilation.- Dilation of the esophagus has been a mainstay of achalasia treatment for hundreds of years. Esophageal dilation of the LES for achalasia can be performed under endoscopic or fluoroscopic guidance with solid or pneumatic stents that are significantly larger than standard esophageal stents. Larger dilators or balloons can be used in a single session, but caution should be exercised due to the risk of perforation and bleeding. The reported clinical response to dilatation therapy varies widely, but approximately 60% to 80% of patients will see improvement after 1 session.2 The duration of response is also highly variable, and many patients require intermittent dilations indefinitely. .

Surgery. Originally described by Heller10, the surgical myotomy of the LES has been modified in recent decades and can now be performed laparoscopically. Regardless of the details, with all myotomies, one or more incisions are made at the gastroesophageal junction to cut the muscle fibers causing the esophagus to block. Modern myotomies are sometimes performed at the same time as an antireflux procedure (fundoplication) to avoid long-term complications, but the type of antireflux procedure performed varies depending on regional surgical practice. The only prospective randomized trial comparing dilation with surgical myotomy found that 40 (95%) of 42 myotomy-treated patients were almost symptom-free over a mean period of 5 years, while only 20 (51%) of 39 patients with the myotomy dilation group. However, not all patients are candidates for surgery and surgical myotomy has associated risks. Recurrent dysphagia can develop several years after myotomy as a result of scarring or an initial incomplete myotomy.

Summary. Oral agents for achalasia are of limited use, while dilation and botulinum toxin may produce a more sustained response. Botulinum toxin may be helpful for elderly patients or poor surgical candidates. Surgical myotomy should be reserved for refractory cases and should be performed using a minimally invasive approach when possible.

Diagnosis

Diffuse esophageal spasm is clinically characterized by intermittent chest pain and dysphagia. Chest pain can range from mild to overwhelming, spread to the back and jaw, and last from seconds to minutes. DES pain does not always occur when swallowing. Belching is rare. Dysphagia in DES patients can be due to solids or liquids and is more common when eating very cold or very hot foods. The classic abnormality seen on esophageal manometry in patients with DES is a pattern of abnormal simultaneous contractions of the esophageal body. Formal testing requires these to be present in more than 30% of wet swallows for a reliable diagnosis.

The symptoms of DES can range from mild to severe, but are usually intermittent. Smaller manometric diagnostic criteria for DES include frequent and repeated (= 3 peaks) contractions of the esophagus with large amplitudes (> 180 mm Hg) that are prolonged (> 6 seconds). Sometimes the LES can have a high base pressure in the DES, but it is usually normal, as is the upper esophageal sphincter12.
The nutcracker esophagus, which also has classic chest pain and dysphagia, is manometrically characterized by a mean peristaltic amplitude of the distal esophagus of more than 180 mm Hg. Smaller criteria for NE are repeated contractions (> 2 peaks) that are prolonged (> 6 seconds). ). The LES expands normally but has a high base pressure greater than 40 mm Hg. 4
In both DES and NE, symptoms can be intermittent, dietary or not, and are generally non-progressive. This lack of symptomatic and manometric progression separates DES and NE from other causes of chest pain and angina, such as achalasia and esophageal cancer.

What is striking is the similarity between the diagnostic criteria of these two entities.

The diagnosis of DES is made using a combination of clinical and manometric criteria, while the diagnosis of EN is based solely on manometry. The question of whether DES and NE actually represent the same unit has been raised several times. In addition, many patients have manifestly abnormal manometric contractions of the esophagus (severe, elongated, etc.), but these contractions do not meet criteria for DES or NE (or even achalasia). These patients can be diagnosed with NSMD and it is not clear how this diagnosis differs from DES and EN. Note that healthy patients may have unusually strong or prolonged manometric contractions without showing symptoms. This finding reflects some of the limitations of esophageal manometry as a diagnostic tool.

For both DES and EN, the specific pathophysiology remains elusive and has led some researchers to wonder whether these are real disorders or simply clusters of symptoms and manometric results.13 This concern is particularly common among patients. It is often seen in healthy patients without dysphagia.

Risk factor

People at risk for esophageal dysmotility are those who have:

  1. Benign or malignant strictures
  2. Motor disorders of the esophagus, including:
  3. Achalasia (where the lower esophageal sphincter does not relax)
  4. Esophageal spasm (in which contractions of the esophagus become
  5. uncoordinated)
  6. Neurological or neuromuscular diseases such as:
  7. multiple sclerosis
  8. Muscular dystrophy
  9. Myasthenia gravis
  10. Myopathy
  11. Peripheral neuropathy
  12. Muscle atrophy in the spine
  13. Myositis, including polymyositis and dermatomyositis
  14. Charcot-Marie-Tooth Disease
  15. Amyotrophic lateral sclerosis (ALS)