Esophageal Motility Disorders

Esophageal Motility Dz

Esophageal Disorders

• Motility
• Anatomic & Structural
Reflux
Infectious
Neoplastic
Miscellaneous
Esophageal Motility Dz

Esophageal Anatomy

Upper Esophageal
Sphincter (IDES)

47

Esophageal Body
(cervical & thoracic)

Lower Esophageal
Sphincter (LES)
 Esophageal Motility Dz

Normal Phases of Swallowing

 Esophageal Motility Dz

Normal Swallowing

Cortical Swallowing Areas

Frontal cortex

Swallowing Center
Brainstem

Motor Nuclei

Oropharynx & Esophagus

 Esophageal Motility Dz

Motility Disorders

diagnostic tools
cineradiology or videofluoroscopy (MBS)
barium esophagram
esophageal manometry
endoscopy
 Esophageal Motility Dz

Motility Disorders

diagnostic tools
cineradiology or videofluoroscopy (MBS)
barium esophagram
esophageal manometry
endoscopy
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 Esophageal Motility Dz

Upper Esophageal Motility Disorders

cause oropharyngeal dysphagia (transfer dysphagia)
patients complain of difficulty swallowing
tracheal aspiration may cause symptoms
pharyngoesophageal neuromuscular disorders
stroke
Parkinson's
poliomyelitis
ALS
multiple
sclerosis
myasthenia
diabetes gravis
dermatomyositis and polymyositis
upper esophageal sphincter (cricopharyngeal) dysfunction
Esophageal Motility Dz

UES Disorders
 Esophageal Motility Dz

Motility Disorders of the Body & LES

symptoms: usually dysphagia (intermittent and
occurring
with liquids & solids)diagnostic tests
barium esophagram
endoscopy
esophageal manometry
disorders
achalasia
diffuse esophageal spasm (DES)
nutcracker esophagus
hypertensive LES
nonspecific esophageal dysmotility
hypomotility
hypermotlity
 •
Esophageal Motility Dz

Achalasia
treatment - reduce LES pressure and increase emptying
— nitrates and calcium channel blockers
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects

— botulinum toxin (prevents ACH release at NM junction)

• 90% initial response; 60% at 1 year

pneumatic dilation (disrupt circular muscle)

• 60-95% initial success; 60% at 5 years
recent series suggest 20-40% will require re-dilation
risk of perforation 1-13% (usually 3-5%); death 0.2-0.4%
surgical myotomy (open or minimally-invasive)
›90% initial response; 85% at 10 years; 70% at 20 years (85% at 5
years with min. inv. techniques)
<1% mortality; <10% major morbidity
10-25% acutely develop ref lux, up to 52% develop late ref lux
 •
Esophageal Motility Dz

Achalasia
treatment - reduce LES pressure and increase emptying
— nitrates and calcium channel blockers
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects

— botulinum toxin (prevents ACH release at NM junction)

• 90% initial response; 60% at 1 year

pneumatic dilation (disrupt circular muscle)

• 60-95% initial success; 60% at 5 years
recent series suggest 20-40% will require re-dilation
risk of perforation 1-13% (usually 3-5%); death 0.2-0.4%
surgical myotomy (open or minimally-invasive)
›90% initial response; 85% at 10 years; 70% at 20 years (85% at 5
years with min. inv. techniques)
<1% mortality; <10% major morbidity
10-25% acutely develop ref lux, up to 52% develop late ref lux
 •
Esophageal Motility Dz

Achalasia
treatment - reduce LES pressure and increase emptying
— nitrates and calcium channel blockers
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects

— botulinum toxin (prevents ACH release at NM junction)

• 90% initial response; 60% at 1 year

pneumatic dilation (disrupt circular muscle)

• 60-95% initial success; 60% at 5 years
recent series suggest 20-40% will require re-dilation
risk of perforation 1-13% (usually 3-5%); death 0.2-0.4%
surgical myotomy (open or minimally-invasive)
›90% initial response; 85% at 10 years; 70% at 20 years (85% at 5
years with min. inv. techniques)
<1% mortality; <10% major morbidity
10-25% acutely develop ref lux, up to 52% develop late ref lux
 •
Esophageal Motility Dz

Achalasia
treatment - reduce LES pressure and increase emptying
— nitrates and calcium channel blockers
• 50-70% initial response; <50% at 1 year
• limitations: tachyphylaxis and side-effects

— botulinum toxin (prevents ACH release at NM junction)

• 90% initial response; 60% at 1 year

pneumatic dilation (disrupt circular muscle)

• 60-95% initial success; 60% at 5 years
recent series suggest 20-40% will require re-dilation
risk of perforation 1-13% (usually 3-5%); death 0.2-0.4%
surgical myotomy (open or minimally-invasive)
›90% initial response; 85% at 10 years; 70% at 20 years (85% at 5
years with min. inv. techniques)
<1% mortality; <10% major morbidity
10-25% acutely develop ref lux, up to 52% develop late ref lux
 Esophageal Motility Dz

Spastic Motility Disorders of the

Esophagus
 Esophageal Motility Dz

Diffuse Esophageal Spasm

frequent non-peristaltic
contractions
simultaneous onset (or too
rapid propagation) of
contractions in two or
more recording leads
occur with ›30% of wet
swallows (up to 10% may
be seen in "normals")
 Esophageal Motility Dz

Nutcracker Esophagus

high pressure peristaltic

contractions
avg pressure in 10 wet
swallows is >180 mm Hg ri6rrtFig

I
Scrn
33% have long duration
E 200

contractions (>6 sec)

0

1420 mmHg (1420 immHg

may inter-convert with 11:

DES 6 4
vits 1.0 seconds Ws
 Esophageal Motility Dz

Nonspecifi
Hypertensive
c
LES
Dysmotility
Esophageal

high LES pressure abnormal motility

›45 mm Hg pattern
normal peristalsis fits in no other
often overlaps with category
other motility non-peristalsis in20-
disorders 30% of wet swallows
low pressure waves
(<30 mm Hg)
prolonged contractions
 Esophageal Motility Dz

Spastic Motility Disorders of the

Esophagus
 Esophageal Motility Dz

Spastic Motility Disorders of the

Esophagus
 Esophageal Motility Dz

Manometry in Esophageal Symptoms

Non-Cardiac Chest Pain Dysphagia

Normal
75%

5%

JE Richter, Ann Int !Wed 1987

 Esophageal Motility•••
Dz

Hypomotilty Disorders

secondary
scieroderma
in ›75% of patients
progressive, resulting in aperistals[s in smooth-muscle region
incompetent LES with reflux
other "connective tissue diseases"
CREST
polymyositis & dermatomyositis
diabetes
60% with neuropathy have abnormal motility on testing (most asx)
other
hypothyroidism, alcoholism, amyloidosis
 Esophageal Motility•••
Dz

Hypomotilty Disorders

secondary
scieroderma
in ›75% of patients
progressive, resulting in aperistals[s in smooth-muscle region
incompetent LES with reflux
other "connective tissue diseases"
CREST
polymyositis & dermatomyositis
diabetes
60% with neuropathy have abnormal motility on testing (most asx)
other
hypothyroidism, alcoholism, amyloidosis
 Esophageal Motility Dz

Nonischemic Chest Pain

remains poorly understood (functional chest pain)
enthusiastic investigation finds numerous associations in studies
— psychiatric disorders (depression, panic or anxiety disorder...)
esophageal disorders (GERD, motility disorders...)
mUSCUloskeletal disorders
cardiac disease (microvascular, MVP, tachyarrhythmias...)
GERD is by far the most common, diagnosable, esophageal cause
50-60% of patients have heartburn or acid regurgitation symptoms
50% have abnormal esophageal pH studies (not always correlating to sxs)
very low incidence of endoscopic findings
"PPI Test" may be best and most cost-effective approach
a small subset of patients with non-GERD NCCP display a variety of
esophageal motility disorders
symptoms and motility findings correlate poorly
esophageal hypersensitivity./hyperalgesia may explain the symptoms