Esophageal Motility Disorders

Introduction

• Esophageal motility disorders: Issues with the esophagus's ability to move food and fluids to the stomach.
• Disorders involve malfunctioning of either nerves innervating the esophagus or the esophageal muscles.
• Common symptom: Dysphagia (difficulty swallowing).
  • Affects both solids and liquids.

Mechanism

• Nerve Dysfunction: Affects nitric oxide and vasoactive intestinal peptide release.
  • These chemicals relax the esophageal muscles.
  • Damage leads to decreased relaxation, resulting in high muscle tone.
• Muscle Dysfunction: Issues in the esophageal muscle itself.

Complications

• Esophageal Cancer Risk: Particularly increased in conditions like achalasia and esophageal scleroderma.
• Aspiration Risk: Due to inability to move food/fluid properly, leading to aspiration into the airway.

Types of Esophageal Motility Disorders

1. Achalasia

   • Caused by damage to the myenteric plexus.
   • Symptoms: Increased lower esophageal sphincter tone, decreased mid/distal esophageal motility.
   • Secondary cause: Trypanosoma cruzi (can cause megaesophagus).

2. Diffuse Esophageal Spasm

   • Normal lower esophageal sphincter tone, but high and disorganized motility.
   • Symptoms include dysphagia and intense chest pain.

3. Esophageal Scleroderma

   • Involves atrophy and fibrosis of the esophagus.
   • Symptoms include decreased esophageal sphincter tone and motility.
   • Associated with CREST syndrome (Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia).

Diagnostic Approach

• Barium Swallow

  • Achalasia: Bird's beak appearance.
  • Diffuse esophageal spasm: Corkscrew appearance.

• EGD with Biopsy

  • Used to rule out malignancy, especially in achalasia.

• Manometry (Gold Standard)

  • Measures pressures and contractions at different esophageal levels.
  • Achalasia: Low mid/distal tone, high lower esophageal sphincter tone.
  • Diffuse spasm: High uncoordinated contraction.
  • Scleroderma: Poor contractility.

Treatment

Achalasia

• Medications: Calcium channel blockers (e.g., amlodipine), nitrates (e.g., isosorbide dinitrate).
• Severe Cases:
  • Pneumatic Dilation: Balloon inflation to open lower esophageal sphincter.
  • Heller's Myotomy: Surgical cutting to reduce sphincter tone.
• Alternative: Botulinum toxin injections.

Diffuse Esophageal Spasm

• Medications: Calcium channel blockers and nitrates to relax the esophagus.

Esophageal Scleroderma

• Management: Use of PPIs to prevent esophagitis. No effective surgical options due to systemic nature.

Key Points

• Achalasia benefits more from surgical interventions (pneumatic dilation, Heller’s myotomy).
• Diffuse esophageal spasm responds well to medical therapy.
• Scleroderma primarily managed with PPIs and symptomatic treatment.