1. Esophageal Motility Disorders
BY : Niloofar Azizi

2. 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 .

3. 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

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

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

6. 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

7. 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

8. 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

9. 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

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

11. diagnosis
swallow evaluation & modified barium swallow

12. 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

13. Achalasia
failure to relax which is said of any sphincter that remains in a constant state of tone with periods of relaxation
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14. 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

15. clinical presentation
dysphagia
regurgitation
weight loss
heartburn
postprandial choking
nocturnal coughing

16. 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

17. 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

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

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

20. 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

21. Treatment Nonsurgical Pharmacologic endoscopic intervention
Surgical : long esophagomyotomy

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

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

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

25. 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

26. 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

27. treatment Endoscopic: hydrostatic balloon dilation
surgical intervention:
laparoscopic modified Heller esophagomyotomy
partial antireflux procedure (e.g., a Dor or Toupet fundoplication)
Botox injections
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28. 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

29. 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).

30. Summery

31. THANK YOU!