Esophageal motility disorders: Clinical manifestations, diagnosis, and management
- Donald O Castell, MD
Donald O Castell, MD
- AGA Peer Reviewer
- Professor of Medicine
- Director, Esophageal Disorders Program
- Medical University of South Carolina
Esophageal motility is considered abnormal if motility findings exceed two standard deviations from those found in a large group of normal subjects . While the clinical implications of some esophageal motility disorders such as achalasia are clear, there is considerable controversy concerning the clinical implications of other esophageal motility abnormalities found on esophageal manometry testing and whether they cause or explain the patient's symptoms.
This topic will review the pathophysiology, clinical features, diagnosis, and management of three specific abnormal esophageal motility patterns: diffuse (distal) esophageal spasm (DES), and the hypercontracting esophageal motility disorders of hypertensive peristalsis (nutcracker esophagus) and hypertensive lower esophageal sphincter (LES). The pathophysiology, clinical features, and management of achalasia and the evaluation and management of chest pain of esophageal origin are discussed separately. (See "Pathophysiology and etiology of achalasia" and "Achalasia: Pathogenesis, clinical manifestations, and diagnosis" and "Overview of the treatment of achalasia" and "Evaluation of the adult with chest pain of esophageal origin".)
Esophageal motility disorders may occur as isolated phenomena (primary) or associated with other diseases (secondary) (table 1 and table 2). Using conventional esophageal manometry, primary esophageal abnormalities are classified as achalasia and other abnormal motility patterns and further subclassified into those with hypercontracting, hypocontracting, or discoordinated motility (table 1).
Based on high resolution manometry (HRM) with esophageal pressure topography (EPT), esophageal motility disorders are classified according to the Chicago Classification [2-4]. The Chicago Classification divides esophageal motility disorders according to the relaxation of the lower esophageal sphincter (LES), as measured by the integrated relaxation pressure (IRP). Once LES relaxation has been characterized, motility disorders are then further categorized based on abnormalities in esophageal peristalsis. Findings on HRM with EPT largely correlate with findings on conventional manometry (table 3). (See "High resolution manometry", section on 'Overview'.)
There are limited data on the prevalence of diffuse (distal) esophageal spasm (DES) and hypercontracting esophageal motility abnormalities (hypertensive peristalsis [nutcracker esophagus] and hypertensive lower esophageal sphincter). In one study that included 1480 individuals referred for esophageal manometry for evaluation of dysphagia or chest pain, the prevalence of manometric findings consistent with DES was 4 percent . In another study, manometric findings consistent with nutcracker esophagus were noted in 12 percent of patients with unexplained chest pain .
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- CLINICAL FEATURES
- Clinical manifestations
- Imaging findings
- Diagnostic approach
- Esophageal manometry
- - Diffuse (distal) esophageal spasm
- - Hypertensive peristalsis (nutcracker esophagus)
- - Hypertensive lower esophageal sphincter
- DIFFERENTIAL DIAGNOSIS
- Initial therapy
- Subsequent therapy
- SUMMARY AND RECOMMENDATIONS