BY : Niloofar Azizi Esophageal Motility Disorders.

BY : Niloofar Azizi

Esophageal Motility Disorders

• 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 .

Esophageal Anatomy

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 EsophagealSphincter

(UES)

Esophageal Body

(cervical & thoracic)

Lower EsophagealSphincter

(LES)

18 to 24 cm

1. cricopharyngeus muscle (14 mm)

2. bronchoaortic constriction (15 – 17 mm)

3. diaphragmatic constriction (16 – 19 mm)

Anatomic Narrowing

• 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

Normal Phases of Swallowing

• upper esophageal– UES disorders– neuromuscular disorders

• esophageal body– achalasia– diffuse esophageal

spasm– nutcracker esophagus– nonspecific esophageal

dysmotility• LES

– achalasia– hypertensive LES

• primary disorders– achalasia– diffuse esophageal

spasm– nutcracker esophagus– nonspecific esophageal

dysmotility

• secondary disorders– severe esophagitis– scleroderma– diabetes– Parkinson’s– stroke

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

Upper Esophageal Motility Disorders

• cricopharyngeal hypertension– 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

UES Disorders

• localizes as upper (cervical) dysphagia within seconds of swallowing

• coughing• choking• immediate regurgitation or nasal

regurgitation

clinical manifestations

swallow evaluation & modified barium swallow

diagnosis

• 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

hypomotilityhypermotlity

Motility Disorders of the Body & LES

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Achalasia

• failure to relax which is said of any sphincter that remains in a constant state of tone with periods of relaxation

epidemiology

1

2

6 per 100,000 populationis seen in young women and middle-aged men and women alike.

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)

1. destruction of the nerves to the LES

2. degeneration of the neuromuscular function of the body

dysphagia regurgitation weight loss heartburn postprandial choking nocturnal coughing

clinical presentation

esophagram

motility study1. hypertensive LES (> 35 mm Hg)2. fail to relax 3. a pressure above baseline4. simultaneous mirrored contractions

with no evidence of progressive peristalsis

5. low-amplitude waveforms

diagnosis

surgical 1. Esophagomyotomy (Heller myotomy)2. Esophagectomy 3. resectionnonsurgical 4. medications : sublingual nitroglycerin,

nitrates, or calcium channel blockers, Injections of botulinum toxin

5. endoscopic : Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon

treatment

Diffuse Esophageal Spasm

• Hypermotility disorder of the esophagus

• esophageal contractions are repetitive, simultaneous, and of high amplitude

1 female > male

epidemiology

Muscular hypertrophy and degeneration of the branches of the vagus nerve in the esophagus

pathology

2

chest pain DysphagiaRegurgitation

Symptoms and Diagnosis

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

NonsurgicalPharmacologicendoscopic intervention

Surgical : long esophagomyotomy

Treatment

Nutcracker Esophagus

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

chest pain dysphagia Odynophagia

Symptoms and Diagnosis

subjective complaint of chest pain with simultaneous objective evidence of peristaltic esophageal contractions on manometric tracings

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

foods

treatment

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

chest pain dysphagia

Symptoms and Diagnosis

Manometry:elevated LES pressure (>26 mm Hg) and normal relaxation of the LES

Esophagram:narrowing at the GEJ with delayed flow

Endoscopic:hydrostatic balloon dilation surgical intervention:1. laparoscopic modified Heller

esophagomyotomy2. partial antireflux procedure (e.g., a Dor

or Toupet fundoplication) Botox injections

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treatment

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

chest pain Dysphagia tend to experience more reflux

symptoms and regurgitation

Symptoms and Diagnosis

barium esophagrammanometric 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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