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
pathology2
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 LESEsophagram: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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