Motility disorders

Question 1

What are motility disorders of oesophagus

Answer 1

• Abnormal peristalsis
• Present with difficulty swallowing usually solids and liquids
• Less common than inflammatory or malignancy of oesophagus

Question 2

Anatomy of oesophagus - part and type of muscle

Answer 2

• Upper 1/3 - skeletal muscle
• Middle 1/3 - transition zone of both skeletal and smooth muscle
• Lower 1/3 - smooth muscle

Question 3

What is LOS vs UOS composed of?

Answer 3

• UOS - skeletal
• LOS - smooth muscle

Question 4

What initiates oesophageal motion?

Answer 4

• Oesophageal myenteric neurones control peristaltic waves
• Primary wave under control of swallowing centre, secondary wave in response to distension

Question 5

What happens as food moves down oesophagus?

Answer 5

LOS relaxes and allows food to pass into stomach

Question 6

What is achalasia?

Answer 6

• Primary motility disorder
• Failure of relaxation of LOS and absence of peristalsis along oesophageal body
• Underlying cause though to be progressive destruction of ganglion cells in myenteric plexus

Question 7

Risk with achalasia

Answer 7

• Increased risk of oesophageal cancer by 8-16x
• Absolute risk remains low though

Question 8

Symptoms of achalasia

Answer 8

• Progressive dysphagia solids and liquids
• Regurgitation of food
• Symptom severity varies day to day
• Others can be respiratory complications eg nocturnal cough, aspiration, chest pain, dyspepsia, weight loss

Question 9

Examination findings for achalasia

Answer 9

• Rarely any signs
• Visible weight loss - secondary to reduced oral intake

Question 10

Investigations for motility disorder presentation

Answer 10

• Anyone with dysphagia - upper GI endoscopy - if severe can be dilated oesophagus with retained food and increased resistance GOJ
• Oesophageal manometry = gold standard

Question 11

What is oesophageal manometry

Answer 11

• Pressure sensitive probe into oesophagus (5cm proximal to LOS)
• Measures pressure of sphincter and surrounding muscle

Question 12

3 key features on manometry of achalasia

Answer 12

• Absence of oesophageal peristalsis
• Failure of relaxation of LOS
• High resting LOS tone

Question 13

Classification of achalasia

Answer 13

• Chicago classification
• Based on contractility pattern in oesophageal body

Question 14

Chicago classification

Answer 14

• Type I - classical achalasia, 100% failed peristalsis, LOS fails to relax completely
• II - pan-oesophageal pressuriation to >30mmHg in 20% of swallows at least, no normal peristalsis
• III - no normal peristalsis, preserved fragments of distal peristalsis OR premature contractions in more than 20% of swallows

Question 15

Conservative management achalasia

Answer 15

• Sleeping with multiple pillows - reduce regurgitation
• Eating slowly
• Chewing food thoroughly
• Plenty of fluid with meals

Question 16

Pharmacological options for achalasia

Answer 16

• CCBs - typically subligual Nifedipine to inhibit LOS contraction BUT benefit short lived
• Botox injections into LOS via endoscopy can be trialled, effects only last few months though

Question 17

Surgical options for achalasia

Answer 17

• Laparascopic Heller Myotomy (cardiomyotomy)
• Per oral endoscopic myotomy (POEM)
• Endoscopic balloon dilatation

Question 18

Laparascopic heller myotomy (cardiomyotomy)

Answer 18

• Division of specific fibres of LOS which fail to relax
• Only divide muscle fibres and avoid mucosal breach

Question 19

Per oral endoscopic myotomy

Answer 19

• Cardiomyotomy at LOS performed from inside lumen of oesophagus - through a submucosal tunnel
• Post op rates of GORD are high though but good clinical response

Question 19

Laparascopic heller myotomy vs other approaches

Answer 19

• Long term swallowing improvement in 85%
• Lower side effects than endoscopic
• Reflux becomes a problem after so partial fundoplication usually done at same time

Question 20

Endoscopic balloon dilatation

Answer 20

• Insertion of balloon into LOS which is dilated to stretch muscle fibres
• Good response initially but risk of perforation and need for further intervention later

Question 21

Management of end stage refractory achalasia

Answer 21

• May need oesophagectomy eventually
• If unsuitable, cardioplasty (cutting out LOS and anastomosing) may be done

Question 22

What is diffuse oesophageal spasm?

Answer 22

• Multi-focal high amplitude contractions of oesophagus
• Dysfunction of oesophagus inhibitory nerves
• Sometimes can progress to achalasia

Question 23

Symptoms of diffuse oesophageal spasm

Answer 23

• Severe dysphagia - solids and liquids
• Central chest pain - exacerbated by food
• Pain can respond to nitrates - due to relaxation of muscle, making if difficult to distinguish from angina

Question 24

Examination diffuse oesophageal spasm

Answer 24

normal - like achalasia

Question 25

Investigations for DOS

Answer 25

• Need upper GI endoscopy first - like any dysphagia
• Then definitve diagnosis via manometry
• Barium swallow less commonly used but can reveal corkscrew appearance

Question 26

Manometry findings for diffuse oesophageal spasm

Answer 26

• Repetitive, simultaneous contractions of oesophagus
• Concurrent dysfunction of LOS

Question 27

Management diffuse oesophageal spasm

Answer 27

• CCB - relax smooth muscle in oesophagus
• Pneumatic dilation or Heller myotomy if refractory

Question 28

Other causes of dysmotility

Answer 28

• Autoimmune and CTD disorders
• eg systemic sclerosis (most common), polymyositis and dermatomyositis
• Managed via treating underlying disease, nutritional modification and PPIs as needed