6. Oesophageal Motility Disorders

 

 

Overview

Oesophageal motility disorders involve abnormalities in oesophageal peristalsis and/or dysfunction of the esophagogastric junction (EGJ), resulting in dysphagia, chest pain, and regurgitation. High-resolution manometry (HRM) is the gold standard diagnostic tool.

Diagnostic Tools and Interpretation of Oesophageal Manometry

High-Resolution Oesophageal Manometry (HRM)

  • Procedure: Catheter placement to record esophageal pressure during wet swallows (typically 5 mL water bolus).
  • Key Metrics:
    • Integrated Relaxation Pressure (IRP): Assesses deglutitive lower esophageal sphincter (LES) relaxation. Normal IRP values vary based on patient position (supine vs upright) and manufacturer.
    • Distal Contractile Integral (DCI): Measures oesophageal contraction strength.
    • Distal Latency (DL): Measures timing of peristalsis.

Functional Lumen Imaging Probe (FLIP)

  • Assesses EGJ distensibility and oesophageal contractility.
  • Useful when HRM findings are inconclusive.

Timed Barium Esophagram (TBE)

  • Measures oesophageal emptying time and assesses retained barium at intervals.

Disorders of EGJ Outflow

Achalasia

  • Pathophysiology: Loss of inhibitory neurons in the myenteric plexus leading to failure of LES relaxation.
  • Clinical Features:
    • Progressive dysphagia to solids and liquids.
    • Regurgitation of undigested food.
    • Chest pain and weight loss.

Manometric Subtypes (Chicago Classification v4.0):

Type

LES Relaxation (IRP)

Peristalsis

Key Findings

Type I (Classic)

Impaired

Absent

No oesophageal pressurization.

Type II

Impaired

Absent

Pan-oesophageal pressurization (≥20% swallows).

Type III (Spastic)

Impaired

Absent or premature

≥20% premature contractions (DL <4.5 sec).

Diagnostic Features:

  • HRM: Elevated median IRP (>15 mmHg supine).
  • TBE: Bird’s beak narrowing.
  • Endoscopy: Retained saliva and food, puckered EGJ.
  • FLIP: EGJ diameter <13 mm, reduced distensibility index (DI).

Treatment:

  • Peroral Endoscopic Myotomy (POEM): First-line for Type III achalasia.
  • Laparoscopic Heller Myotomy (LHM): Often combined with fundoplication to reduce reflux.
  • Pneumatic Dilation (PD): Non-surgical option for Type II.

.1 Perform dilatation with pneumatic balloons 30–40mm in diameter starting at 30mm in the first session to reduce the risk of complications 2. Perform a second dilatation session 2–28 days later with a larger size balloon of 35mm 3. Consider repeat dilatation (after the initial series) during follow-up to maintain symptom response 4. Perform dilatation under endoscopic or fluoroscopic control based on clinician’s preference 5. Consider proton pump inhibitor (PPI) therapy after dilatation as the technique has 10–40% rate of symptomatic gastro-oesophageal reflux disease (GORD) or ulcerative oesophagitis after treatment

  • Botulinum Toxin Injection: Temporary relief for patients unfit for surgery.

Esophagogastric Junction Outflow Obstruction (EGJOO)

  • Definition: Elevated IRP with preserved peristalsis but without criteria for achalasia.
  • Causes:
    • Mechanical: Hiatal hernia, fundoplication wrap.
    • Functional: Opioid-induced dysfunction.
  • Diagnostic Confirmation:
    • HRM: Elevated IRP in both supine and upright positions.
    • TBE: Retained barium.
    • FLIP: Decreased EGJ-DI.
  • Treatment:
    • Conservative approach for mild cases (spontaneous resolution possible).
    • Endoscopic dilation or botulinum toxin injections for symptomatic cases.

Disorders of Oesophageal Peristalsis

Distal Oesophageal Spasm (DES)

  • Manometric Criteria: ≥20% premature contractions (DL <4.5 seconds) with normal IRP.
  • Clinical Features:
    • Intermittent dysphagia.
    • Non-cardiac chest pain.
    • Corkscrew oesophagus on imaging.
  • Treatment:
    • Calcium channel blockers or nitrates.
    • Botulinum toxin injections.
    • POEM or myotomy for severe cases.

Hypercontractile (Jackhammer) Oesophagus

  • Manometric Criteria: ≥20% swallows with DCI >8000 mmHg·s·cm.
  • Clinical Features:
    • Severe chest pain.
    • Occasional dysphagia.
  • Treatment:
    • Smooth muscle relaxants (e.g., diltiazem).
    • Botulinum toxin injections.
    • POEM for refractory cases.

Hypomotility Disorders

Ineffective Oesophageal Motility (IEM)

  • Manometric Criteria: ≥70% ineffective swallows (DCI <450 mmHg·s·cm).
  • Clinical Relevance: Often associated with gastroesophageal reflux disease (GERD).
  • Treatment:
    • Focus on reflux control.
    • Lifestyle modifications and dietary adjustments.

Absent Contractility

  • Manometric Criteria: 100% failed peristalsis (DCI <100 mmHg·s·cm) with normal IRP.
  • Causes: Often secondary to systemic sclerosis or severe GERD.
  • Treatment:
    • Esophageal dilation.
    • Acid suppression therapy.

Secondary Oesophageal Dysmotility

Opioid-Induced Oesophageal Dysfunction

  • Clinical Features: Dysphagia, spastic disorders (e.g., EGJOO, type III achalasia).
  • Management:
    • Discontinuation or change of opioid.
    • Botulinum toxin injections or dilation if necessary.

Post-Surgical Oeophageal Motility Disorders

  • Common after antireflux surgery or bariatric surgery.
  • Diagnostic Approach: Endoscopy, HRM, and FLIP to assess the surgical site.
  • Treatment: Endoscopic dilation or wrap takedown in resistant cases.