Esophageal Movement Disorders: A Detailed Clinical Overview

Structure of Esophagus

The esophagus is a hollow tube. It has an upper and lower esophageal sphincter. Its body shows peristaltic contractions. The lower esophageal sphincter at an appropriate time relaxes the passage of food into the stomach.

Chicago Classification

It is put forth based on the gold standard for the evolution of esophageal motility disorder, i.e., high- resolution manometry (HRM).

Categories of Disorder

Disorder of Esophagogastric Junction Obstruction

This disorder is concerned with the lower esophageal sphincter

• Achalasia Cardia
• Esophagogastric Junction Outlet Obstruction

Disorder of Peristalsis

No pathology of LES relaxation

• Ineffective esophageal motility
• Distal esophageal spasm or diffuse esophageal spasm
• Nutcracker or jackhammer esophagus

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Median Integrated Relaxation Pressure

To check whether the lower esophageal relaxation is normal or abnormal by Integrated relaxation pressure (IRP): Do 10 wet swallows, take IRP readings, and take the median

of it. In esophageal obstruction, normally, the median integrated relaxation pressure is > 15 mmHg (Elevated). In disorders of peristalsis, the median integrated relaxation pressure is < 15 mmHg. (Normal)

Distal Contractile Integral (DCI)

DCI is normally less than 450 mm of mercury per square centimeter. It indicates the force/vigor of contraction.

What is Distal Latency (DL)?

It is the time taken from the opening of the esophagus (where the swallowing begins) to the noticing of contractions in the lower end of the esophagus. The lower end of the esophagus should not prematurely contract. Distal latency is used to identify this premature contraction. Normally the latency should be > 4.5 seconds. If the contraction occurs before 4.5 seconds, then it means that it is a premature contraction and is known as reduced distal latency.

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Esophageal HR Manometry

The median IRP of this set of images is > 15 mmHg, so its category of disorder is esophagogastric junction obstruction. So it could be either achalasia cardia or esophagogastric junction outlet obstruction.

Diffuse Esophageal Spasm

It is a peristaltic disorder. It is more common in females than males. It is often associated with other functional bowel disorders such as IBS, acid peptic disease, and functional dyspepsia

and also with psychiatric issues such as anxiety disorders or depression.

Clinical Features

Chest pain and dysphagia. Some of the patients might have regurgitation, but acid reflux

is rare in patients. Diffuse esophageal spasm is 5 times less common in comparison to achalasia cardia.

Evaluation of Patients

Barium Study

Cork-screw esophagus appearance (can be achalasia cardia or diffuse esophageal spasm)

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Manometry (for diagnosis)

• Median IRP: Normal ( <15 mmHg)
• Distal contractile integral: > 450 mmHg/sq.cm
• Distal Latency: < 4.5 seconds (reduced)

Management

Medical

• Smooth Muscle Relaxants: Nitrates, Calcium Channel Blockers, Phosphodiesterase 5 inhibitors (e.g., sildenafil)
• Botulinum injection.
• Antidepressants may be helpful in some subset of patients, such as imipramine, trazodone, or sertraline.

Surgical

Myotomy (long myotomy- proximally, the myotomy is extended till the level of increased contraction and distally LES). 80% of the patients show satisfactory improvement in their symptoms after myotomy.

Nutcracker, Hypercontractile or Esophagus

It can occur in all age groups. There is no predilection for male or female. Peristalsis is present. Normal peristaltic contractions are vigorous. The most common and most painful esophageal motility disorder.

Clinical Features

• Chest pain and dysphagia
• Some of the patients might have regurgitation, but acid reflux is rare in patients.

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Diagnosis

• High-resolution manometry
• Median IRP: normal ( less than 15 mm of mercury)
• Distal contractile integral: more than 8000 mm of mercury per square centimeter

Management

• Drugs like nitrates cause smooth muscle relaxation. Calcium chamber blockers, anxiolytics, and phosphodiesterase 5 inhibitors like sildenafil can also be used. 
• A botulinum injection can be given. 

Important Points to Remember

• The lower esophagus is predominantly composed of smooth muscle.
• The hollow muscular tube connects the oropharynx (hypopharynx) to the stomach.
• The cervical esophagus starts at the end of the hypopharynx and ends at the sternal notch.
• Oropharynx maintains the normal atmospheric pressure.

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