Esophageal Motility Disorders BY : Niloofar Azizi

Esophageal Anatomy The esophagus is a muscular tube that commences at the base of the pharynx at C6 and terminates in the abdomen, where it joins the cardia of the stomach at T11 .

cervical esophagus : begins as a midline structure that deviates slightly to the left of the trachea as it passes through the neck into the thoracic inlet. Thoracic Esophagus : At the level of the carina, it deviates to the right to accommodate the arch of the aorta. It then winds its way back under the left main-stem bronchus. Abdominal Esophagus : Immediately before entering the abdomen, the esophagus is pushed anteriorly by the descending thoracic aorta

Upper Esophageal Sphincter (UES) Esophageal Body (cervical & thoracic) 18 to 24 cm Lower Esophageal Sphincter (LES)

Anatomic Narrowing cricopharyngeus muscle (14 mm) bronchoaortic constriction (15 – 17 mm) diaphragmatic constriction (16 – 19 mm)

Normal Phases of Swallowing Voluntary oropharyngeal phase – bolus is voluntarily moved into the pharynx Involuntary UES relaxation peristalsis LES relaxation Between swallows UES prevents air entering the esophagus during inspiration and prevents esophagopharyngeal reflux LES prevents gastroesophageal reflux

Motility Disorders primary disorders secondary disorders upper esophageal primary disorders UES disorders neuromuscular disorders esophageal body achalasia diffuse esophageal spasm secondary disorders nutcracker esophagus severe esophagitis nonspecific esophageal dysmotility scleroderma LES diabetes Parkinson’s hypertensive LES stroke

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 diabetes myasthenia gravis dermatomyositis and polymyositis upper esophageal sphincter (cricopharyngeal) dysfunction

UES Disorders cricopharyngeal hypertension cricopharyngeal achalasia elevated UES resting tone poorly understood (reflex due to acid reflux or distension) cricopharyngeal achalasia incomplete UES relaxation during swallow may be related to Zenker’s diverticula in some patients

clinical manifestations localizes as upper (cervical) dysphagia within seconds of swallowing coughing choking immediate regurgitation or nasal regurgitation

diagnosis swallow evaluation & modified barium swallow

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

Achalasia failure to relax which is said of any sphincter that remains in a constant state of tone with periods of relaxation Your own footer

is seen in young women and middle-aged men and women alike. epidemiology 1 6 per 100,000 population is seen in young women and middle-aged men and women alike. 2 pathology is presumed to be idiopathic or infectious neurogenic degeneration , Severe emotional stress, trauma, drastic weight reduction, and Chagas' disease (parasitic infection with Trypanosoma cruzi) destruction of the nerves to the LES degeneration of the neuromuscular function of the body

clinical presentation dysphagia regurgitation weight loss heartburn postprandial choking nocturnal coughing

diagnosis esophagram motility study hypertensive LES (> 35 mm Hg) fail to relax a pressure above baseline simultaneous mirrored contractions with no evidence of progressive peristalsis low-amplitude waveforms

treatment surgical Esophagomyotomy (Heller myotomy) Esophagectomy resection nonsurgical medications : sublingual nitroglycerin, nitrates, or calcium channel blockers, Injections of botulinum toxin endoscopic : Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon

Diffuse Esophageal Spasm Hypermotility disorder of the esophagus esophageal contractions are repetitive, simultaneous, and of high amplitude

epidemiology female > male 1 pathology 2 Muscular hypertrophy and degeneration of the branches of the vagus nerve in the esophagus

Symptoms and Diagnosis chest pain Dysphagia Regurgitation Esophagram manometric studies : simultaneous, multipeaked contractions of high amplitude (>120 mm Hg) or long duration (>2.5 sec) erratic contractions occur after more than 10% of wet swallows

Treatment Nonsurgical Pharmacologic endoscopic intervention Surgical : long esophagomyotomy

Nutcracker Esophagus - a hypermotility disorder also known as supersqueeze esophagus - hypertensive peristalsis or high-amplitude peristaltic contractions

Symptoms and Diagnosis chest pain dysphagia Odynophagia subjective complaint of chest pain with simultaneous objective evidence of peristaltic esophageal contractions on manometric tracings

treatment Medical: Calcium channel blockers, nitrates, and antispasmodics Bougie dilation avoid caffeine, cold, and hot foods

Hypertensive LES LES pressure is above normal, and relaxation will be incomplete but may not be consistently abnormal. The motility of the esophageal body may be hyperperistaltic or normal

Symptoms and Diagnosis chest pain dysphagia Manometry: elevated LES pressure (>26 mm Hg) and normal relaxation of the LES Esophagram: narrowing at the GEJ with delayed flow

treatment Endoscopic: hydrostatic balloon dilation surgical intervention: laparoscopic modified Heller esophagomyotomy partial antireflux procedure (e.g., a Dor or Toupet fundoplication) Botox injections Your Logo

Nonspecific Esophageal Dysmotility abnormal motility pattern fits in no other category Several collagen vascular disorders are known to cause abnormalities of esophageal motility scleroderma, dermatomyositis, polymyositis, and lupus erythematosus

Symptoms and Diagnosis chest pain Dysphagia tend to experience more reflux symptoms and regurgitation barium esophagram manometric studies: incomplete relaxation (residual >5 mm Hg) Contractions of the esophageal body patterns: non-transmitted, triple-peaked, retrograde, low-amplitude (<35 mm Hg) or prolonged duration (>6 sec).

Summery

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