Motility disorders of Esophagus

Dr Sabyasachi SahaModerator: Lt Col Priyaranjan(Gd Spl Surg and GI surgeon)

Physiology

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Classification

• Striated muscle disorders• Smooth muscle disorders

Striated muscle disorders

• Transfer dysphagia/ oropharyngeal dysphagia• Causes:– CVA– Myaesthenia gravis– Parkinson’s disease– Multiple sclerosis

Smooth muscle disorders

• Achalasia• Diffuse esophageal spasm• Nutcracker esophagus• Hypertensive LES

ClassificationDisorders of pharyngo-esophageal junction

Neurological – Stroke, MND, multiple sclerosis, Parkinson’s diseaseMyogenic – myasthenia, muscular dystrophyPharyngo-oesophageal (Zenker’s) Diverticulum

Disorders of body Diffuse oesophageal spasmNutcracker oesophagusAutoimmune disorders – especially systemic sclerosis (CREST)Reflux associatedIdiopathicAllergicEosinophilic oesophagitisNon-specific oesophageal dysmotility

Disorders of LES AchalasiaIncompetent lower sphincter (i.e. GERD)

Approach to Dysphagia

Key questions for Diagnosis of dysphagia

• Is it truly dysphagia?• Is dyphagia for solids, liquids or both?• Is dysphagia intermittent or progressive?• At what level is the obstacle?

Oropharyngeal dysphagia

Video esophagram

Structural

ENT

Neuromuscular

Conservative measures

Surgical interventions

Esophageal dysphagia

Solids

EGD

Solids and liquids

X-ray

Normal

Mannometr

y

Abnormal

Structural

EGD/Biopsy

Neuromuscular Mannometry

Esophageal Mannometry

• Define the contractile characteristics of the esophagus to identify and classify motility disorders.

• Manometric evaluation of the tubular esophagus – Assesses the integrity, – Rate of progression, and – Morphology of the contractile complex (amplitude,

duration, repetitive contractions).

Achalasia

• Aperistalsis• Poor LES relaxation• High or normal LES resting pressure

Achalasia: Pathogenesis

• Patchy inflammation of myenteric plexus: decreased ganglion cells

• Loss of latency gradient across the esophagus: aperistalsis

• Defect of inhibitory neurons: poor LES relaxation

Achalasia: Symptoms

• All age groups– Dysphagia to solids and liquids– Regurgitation– Weight loss: mild, sitophobia– Chest pain (40-50%)– Respiratory symptoms

Mannometry

5 classical findings

• Abnormalities of the LES– Failure to relax with deglutition– Hypertension >35 mm-Hg

• Abnormalities of the esophageal body– Pressure above the baseline (pressurisation)– Simultaneous mirrored contractions with no e/o

progressive peristalsis– Low amplitude waveforms

Achalasia: Treatment goal

• Reduce the gradient of pressure represented by LES

Treatment options

Medical

NitratesCCBs

Botox

Endoscopic intervention

Pneumatic dilation

Surgical

Heller’smyotomy

Pharmacotherapy for achalasia

• Brief action• Common side effects• Partial symptom relief• Reserved for patients who are ineligible for or

refuse other treatment.

Pneumatic dilation

• Outpatient procedure• Combined with endoscopy• Fluoroscopic assistance• Perforation:– Independent of age– Role of technique?– Frequency: 2-3 %– Requires thoracotomy

Pneumatic dilation

Surgical myotomy

Surgical myotomy

Open

Transabdomi

nal Transt

horacic

Laparoscopic myotomy and

fundoplication

POEM

• Per Oral Endoscopic Myotomy

Botulinum toxin

• Inhibits release of acetyl choline• Lowers LESP > 60 %• 80- 100 units injected endoscopically in four

quadrants

Botulinum toxin: IndicationsAppropriate Inappropriate

Elderly, frail patients

High surgical risk

Patient refused other treatment

Pseudoachalasia

Young patients

Healthy patients

Diagnosis doubtful

Treatment of Achalasia

Good surgical risk Poor surgical risk

Good surgical risk

Laparoscopic myotomy

Failure

Pneumatic dilation

Failure

Esophagectomy

Success

Success

Good surgical risk

Pneumatic dilation

Failure

Laparoscopic myotomy

Success

Poor surgical risk

Botilinum toxin

Failure

Repeat

Failure

Palliatio

n Vs. interventio

n

Success

Success

Repeat as needed

Non-cardiac chest pain

72

28

Normal motilityAbnormal motility

Non-cardiac chest pain with abnormal motility

48

36

10

4 2

NutcrackerNEMDDESHypertensive LESAchalasia

Diffuse esophageal spasm

• Dysphagia• Chest pain- mimic angina• Motor abnormality of lower 2/3 esophageal

body• Repetitive, simultaneous, high amplitude,

spastic contractions• Presence of peristaltic contractions

Esophagram

Mannometry

Treatment

• Psychiatric evaluation• Eliminate trigger foods/ drinks• Pharmacologic/ endoscopic- preferred• Surgery- reserved

Nutcracker/ Supersqueeze esophagus

• High amplitude (> 180 mm-Hg)• Long duration (> 6 seconds)• Peristaltic contractions• Differential diagnosis of chest pain• Most painful• LES pressure & relaxation- normal• Pharmacologic/ endoscopic- preferred

Mannometry

Hypertensive LES

• Dysphagia, chest pain• Mannometry: Elevated LES pressure• LES relaxation: incomplete but may not be

consistently abnormal• Esophageal body: hyperperistaltic/ normal• Botox/ baloon dilation• Lap Heller’s myotomy

Take home message

• Dysphagia:– Deserves attention at any age– X-ray and EGD reliable and effective in most cases– Carefully obtained history essential

• Bailey and love’s short practice of surgery• Sabiston textbook of surgery• Shackelford’s surgery of the alimentary tract

Thank you