Motility Disorders of Esophagus

Motility Disorders of Oesophagus
Hilal Saleem, 59
1. Hypermotility disorder,
e.g: cricopharyngeal spam,
diffuse oesophageal spasm (DES),
nut cracker oesophagus.
2. Hypomotility disorders
Eg: cardiac achalasia,
gastro oesophageal reflux,
scleroderma,
amyotrophic lateral sclerosis
CRICOPHARYNGEAL
SPASM
It is caused by failure of the upper oesophageal sphincter to
relax properly. There is incoordination between relaxation of
the upper oesophageal sphincter and simultaneous
contraction of the pharynx.
(when the cricopharyngeus muscle around the esophagus
cannot relax, preventing food from entering the esophagus
properly.)
The common causes are cerebrovascular accidents,

Parkinson's disease, bulbar polio, multiple sclerosis and
muscular dystrophies.
DIFFUSE OESOPHAGEAL SPASM
It is characterized by strong non peristaltic contractions of

the body of oesophagus while sphincteric relaxation is
normal. The symptoms consist of dysphagia or odynophagia
with substernal chest pain, simulating angina pectoris.
Barium swallow may show segmented oesophageal spasms
giving a rosary bead or a cork-screw type of oesophagus,
though it may be normal in some. Manometry shows normal
relaxation of the sphincter on swallowing. The treatment is
dilatation of lower oesophagus. Severe cases may require
myotomy of oesophagus from the arch of aorta to lower
sphincter
DIFFUSE OESOPHAGEAL SPASM
It is characterized by strong non peristaltic contractions of

the body of oesophagus while sphincteric relaxation is
normal. The symptoms consist of dysphagia or odynophagia
with substernal chest pain, simulating angina pectoris.
Barium swallow may show segmented oesophageal spasms
giving a rosary bead or a cork-screw type of oesophagus,
though it may be normal in some. Manometry shows normal
relaxation of the sphincter on swallowing. The treatment is
dilatation of lower oesophagus. Severe cases may require
myotomy of oesophagus from the arch of aorta to lower
sphincter
NUT-CRACKER OESOPHAGUS
These are strong, high amplitude oesophageal contractions

but the contractions remain peristaltic (compare diffuse
oesophageal spasm where contractions are non peristaltic),
It causes dysphagia and substernal pain.
CARDIAC ACHALASIA
It is characterized by the absence of peristalsis in the body

of oesophagus and high resting pressure in lower
oesophageal sphincter, the latter also does not relax during
wallowing.
The symptoms of cardiac achalasia include dysphagia, which

is more to liquids than solids (reverse of that seen in
malignancy or strictures) and regurgitation of swallowed
food particularly at night.
CARDIAC ACHALASIA
It is characterized by the absence of peristalsis in the body

of oesophagus and high resting pressure in lower
oesophageal sphincter, the latter also does not relax during
wallowing.
The symptoms of cardiac achalasia include dysphagia, which

is more to liquids than solids (reverse of that seen in
malignancy or strictures) and regurgitation of swallowed
food particularly at night.
CARDIAC ACHALASIA
The diagnosis is made by (1) radiography (Barium swallow
show dilated oesophagus with narrowed rat tail end),
sometimes also called bird-beak appearance; (ii)
manometric studies (low pressure in the body of oesophagus
and high pressure at lower sphincter and failure of the
sphincter to relax), (iii) endoscopy (to exclude benign
stricture or any development of carcinoma which is a
common complication of this disorder.
The treatment of choice is the modified Heller's operation

(myotomy of the narrowed lower portion of the oesophagus).
Forceful pneumatic dilatation of the lower oesophagus can
be done in those unfit for surgery.
CARDIAC ACHALASIA
The diagnosis is made by (1) radiography (Barium swallow
show dilated oesophagus with narrowed rat tail end),
sometimes also called bird-beak appearance; (ii)
manometric studies (low pressure in the body of oesophagus
and high pressure at lower sphincter and failure of the
sphincter to relax), (iii) endoscopy (to exclude benign
stricture or any development of carcinoma which is a
common complication of this disorder.
The treatment of choice is the modified Heller's operation

(myotomy of the narrowed lower portion of the oesopha
gus). Forceful pneumatic dilatation of the lower oesophagus
can be done in those unfit for surgery.
GASTRO-OESOPHAGEAL
REFLUX
It is due to decreased function of lower oesophageal
sphincter thus permitting regurgitation of gastric contents
into oesophagus. Other causes of gastro-oesophageal reflux
are pregnancy, hiatus hernia, scleroderma, excessive use of
tobacco and alcohol, and drugs that relax the smooth
muscle (anticholinergic, beta-adrenergic drugs and calcium-
channel blockers).
The symptoms of oesophageal reflex include:

substernal pain, heartburn and regurgitation.
GASTRO-OESOPHAGEAL
REFLUX
The treatment consists of
1. Elevation of the head of bed at night.
2. Avoiding food at least 3 h before bedtime
3. Antacids
4. Drugs that increase tone of lower oesophageal sphincter,
eg. metoclopramide
5. Histamine receptor antagonists, eg. cimetidine and
ranitidine
6. Avoiding smoking, alcohol, caffeine, chocolates, mints and
carbonated drinks.
7. Anti reflux surgery, eg. Nissen's fundoplication
GASTRO-OESOPHAGEAL
REFLUX
The treatment consists of
1. Elevation of the head of bed at night.
2. Avoiding food at least 3 h before bedtime
3. Antacids
4. Drugs that increase tone of lower oesophageal sphincter,
eg. metoclopramide
5. Histamine receptor antagonists, eg. cimetidine and
ranitidine
6. Avoiding smoking, alcohol, caffeine, chocolates, mints and
carbonated drinks.
7. Anti reflux surgery, eg. Nissen's fundoplication
GASTRO-OESOPHAGEAL
REFLUX
COMPLICATIONS OF GASTRO-OESOPHAGEAL REFLUX
1. Oesophagus
Oesophagitis, nesophageal mucosal erosion and
haemorrhage. Benign oesophageal stricture. Barrett's of
oesophagus is replaced by columnar epithelium as a result
of continuous inflammation). It is a precancerous condition.
2. Lung
Aspiration pneumonia.
Asthma
Bronchiectasis
3. Larynx
Posterior laryngitis causing vague pain in throat, hoarse- ness
and repeated throat clearing Pachydermia laryngis.
Contact ulcers and granulomas.
Posterior glottic stenosis. Paroxysmal laryngospами.
Carcinoma larynx
4. Ear
Otitis media with effusion.
5. Miscellaneous
Globus hystericus.
SCLERODERMA
systemic collagen disorder primarily neural, but secondarily
weakening the smooth muscles of the lower two-thirds of
oesophagus and the lower oesophageal sphincter.
Dysphagia may precede cutaneous lesions.
Barium swallow shows absence of peristalsis in distal two

thirds of the oesophagus. Many of these patients have
hiatus hernia, or reflux oesophagitis and may develop
stricture in distal part of the oesophagus due to recurrent
inflammation.
SCLERODERMA
systemic collagen disorder primarily neural, but secondarily
weakening the smooth muscles of the lower two-thirds of
oesophagus and the lower oesophageal sphincter.
Dysphagia may precede cutaneous lesions.
Barium swallow shows absence of peristalsis in distal two

thirds of the oesophagus. Many of these patients have
hiatus hernia, or reflux oesophagitis and may develop
stricture in distal part of the oesophagus due to recurrent
inflammation.
SCHATZKI'S RING
It occurs at the junction of squamous and columnar
epithelium at the lower end of oesophagus and has also
been called lower oesophageal ring. Usually seen in patients
above 50 years of age. Cause is unknown. Symptomatic
patients complain of intermittent dysphagia and some may
even present with bolus obstruction. It may be associated
with hiatus hernia. Treatment is oesophageal dilatation.
SCHATZKI'S RING
It occurs at the junction of squamous and columnar
epithelium at the lower end of oesophagus and has also
been called lower oesophageal ring. Usually seen in patients
above 50 years of age. Cause is unknown. Symptomatic
patients complain of intermittent dysphagia and some may
even present with bolus obstruction. It may be associated
with hiatus hernia. Treatment is oesophageal dilatation.

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Motility Disorders of Oesophagus

The common causes are cerebrovascular accidents,

It is characterized by strong non peristaltic contractions of

It is characterized by strong non peristaltic contractions of

These are strong, high amplitude oesophageal contractions

It is characterized by the absence of peristalsis in the body

The symptoms of cardiac achalasia include dysphagia, which

It is characterized by the absence of peristalsis in the body

The symptoms of cardiac achalasia include dysphagia, which

The treatment of choice is the modified Heller's operation

The treatment of choice is the modified Heller's operation

The symptoms of oesophageal reflex include:

Barium swallow shows absence of peristalsis in distal two

Barium swallow shows absence of peristalsis in distal two

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