Esophageal Motility Disorders

​When food doesn't move down the esophagus

Normally, a person’s esophagus performs a wave of sequenced contractions, called peristalsis, to move food from the throat to the stomach. When peristalsis is impaired, the most common diagnosis is achalasia. It is a rare disorder in which the lower esophageal sphincter (LES), a ringed muscle that acts as a valve between the esophagus and stomach, does not relax. This failure inhibits food from passing easily to the stomach.

Other esophageal motility (movement) disorders exist, as well. These disorders differ in a number of criteria, most relating to the strength, sequence and other characteristics of the esophagus’ muscle contractions, the problematic area(s) of esophagus, and whether the patient also is having chest pain, dysphagia (difficulty swallowing), or other symptoms:

Achalasia: Normally, a person’s esophagus performs a series of contractions, called peristalsis, to move food from the throat to the stomach. Achalasia is a rare disorder in which the lower esophageal sphincter (LES), a ringed muscle that acts as a valve between the esophagus and stomach, does not relax. Its failure to relax is combined with a failure of peristalsis in the esophagus. In patients with achalasia, food and liquid collect in the esophagus until their mass creates sufficient pressure to push through the sphincter. The condition tends to progressively worsen with time.

Distal esophageal spasm (DES): Formerly known as “diffuse” esophageal spasm, this condition is marked by simultaneous contractions along the lower esophagus during swallows. Simultaneous contractions – instead of a smooth wave of contractions – work against the easy passage of food.

“Nutcracker” esophagus: This condition is marked by muscle contractions of high pressure. The contractions can be intermittent and occur in the presence or absence of food in the esophagus. One or more overly strong contractions can stop food in the esophagus.

Hypertensive lower esophageal sphincter: Here the LES, a muscular valve, relaxes normally during a swallow but is under greater pressure at rest. Because of this, patients typically experience chest pain and dysphagia, as well.

In other instances, dysfunction of the esophagus occurs as a symptom of disorders that affect other parts of the body, as well; diabetes and scleroderma are two common examples. Research associates diabetes, a metabolic disorder of the body’s glucose level, with a greater likelihood of gastroesophageal reflux disorder (GERD) and heartburn. This stems from reduced pressure at the LES, which normally keeps food and stomach acids out of the esophagus.

Scleroderma: a disorder that hardens the skin, also might affect the esophagus, making its muscles less functional. If as a result stomach acids get past the LES, it can lead to heartburn and, over time, esophageal scarring.
Any of these esophageal disorders is rare, and they can be difficult to treat effectively. Furthermore, these disorders can be difficult to distinguish from GERD and other more common esophageal disorders, thus require specialists to diagnose and treat them. Medical literature suggests that most patients who develop the conditions are 50 or older, but also describe cases involving infants and children. For some patients, medication such as calcium-channel blockers can make esophageal dysfunctions manageable. Calcium-channel blockers work as muscle relaxants, so reduce contractions in the esophageal muscles and make the LES function more fluidly. In other patients, dilating the LES by mechanical means, or surgery to the esophagus, can relieve or improve symptoms.

Symptoms

Patients with esophageal disorders most commonly experience dysphagia (difficulty swallowing) and chest pain. Patients typically have problems first with solid foods, then with liquids. Other symptoms might include a feeling of chest heaviness, regurgitation and heartburn associated with acid reflux (GERD). Gas and bloating can develop, as well. Patients with long-term symptoms might also lose appetite and weight.
  • Patients with distal esophageal spasm or nutcracker esophagus have higher-than-normal pressures in the esophagus. They would be prone to develop dysphagia, chest pain, and regurgitation because food would be more likely to be trapped in the esophagus. Pain can be mild or severe, frequent or intermittent, and last only a moment or several minutes. In some case pain, literature says, patients experience pain in the jaw and back, as well.
  • Patients whose conditions involve a relaxed LES would be prone to develop the above symptoms as well as night coughing and reflux. Over time, reflux (GERD) can lead to esophageal scarring, which raises the risk of esophageal cancer. Additionally, reflux is associated with a higher likelihood of chronic cough, asthma and laryngitis.

Causes

The cause(s) of primary esophageal disorders has not been established. Theories include imbalances of chemicals, including acetylcholine, involved in nerve signals, and compression of the vagus nerve in the brainstem. That nerve extends from the head to the abdomen. Dysfunctions stemming from secondary conditions such as diabetes and scleroderma have unrelated causes. Some physicians have suggested that distal esophageal spasm and nutcracker esophagus be symptoms of GERD and are not, in fact, distinct disorders. This suggestion’s basis is the prevalence of abnormal esophageal pH tests in a large portion of those patients.

Risk Factors

These are rare disorders. The most frequent among them, nutcracker esophagus, is experienced by perhaps 10,000-12,000 people in the United States. Obesity is a major risk factor for developing esophageal motility disorders. Alcoholism and anxiety disorders also have been associated with esophageal dysfunction. Otherwise, research does not strongly correlate esophageal disorders with age, sex or reported use of tobacco. Medical literature has linked these disorders with a higher-than-normal prevalence of hiatal hernia, and with patients who also have [esophageal diverticula] – small, bulging pouches in that often are benign but might become inflamed.

Diagnosis

Several tests help diagnose and differentiate esophageal dysfunctions are diagnosed with a small group of tests: manometry, barium swallow, multichannel intraluminal impedance monitoring, endoscopy, and 24-hour pH monitoring. Each diagnostic test is outlined below.

Manometry: Manometry records muscle pressure and function inside the esophagus. A thin tube is inserted via the patient’s mouth and positioned in the esophagus. The tube has holes at several points along its length so it can record the pressure of the esophagus’ muscle contractions as they occur, as well as the function of the lower esophageal sphincter (LES). It helps the physician to know whether the contractions are occurring in the correct sequence, and exerting normal pressure – and if not, where along the esophagus the problems exist.

Barium swallow: The patient swallows a solution while a fluoroscope allows the physician to observe the opaque fluid going through the esophagus, stomach and intestines. The ensuing fluoroscopic images (akin to an X-ray), taken over the course of a few hours, can reveal characteristics of a multiple simultaneous contractions.

Multichannel intraluminal impedance (MII): This detects electrical resistance (impedance) inside the esophagus. A thin catheter is inserted through the patient’s nose into the esophagus and stays in place for 24 hours. This tube recognizes and measures reflux or gas emerging from the stomach into the lower esophagus – even when the refluxed material is not acidic. Patients operate a device that records when they've eaten and when they're lying down or sitting up, and when they have any symptoms like coughing or nausea, and this record is aligned with the information recorded by the tube. The test is typically performed in tandem with manometry or pH testing.

24-Hour pH monitoring: Akin to MII monitoring, this test measures acid reflux from the stomach into the esophagus. Using an endoscope, a physician clips a capsule-size probe inside the patient’s esophagus. For a 24-hour period, the probe collects and transmits data about acid refluxing from the stomach (and relieves the patient of wearing a tube in his/her nose). The patient uses a separate recording device to denote periods of eating, sleep and work. Afterward, the patient’s data is aligned with that of the probe, which is made to detach from the esophagus after a week. It is passed out in a stool.

Endoscopy involves the surgeon looking down through the patient’s mouth into the esophagus and stomach. A flexible tube with a tiny camera is inserted via either end and the physician gets a close look at the inside of the digestive tract as the camera’s images are shown on a monitor. Infections and areas of inflammation can be revealed, and if the physician recognizes abnormal tissue, it can be removed for biopsy (done simultaneously with instruments inserted through the tube). Patients may be sedated during the process.

Complications

Esophageal motility disorders create discomfort for patients but typically aren’t associated with severe symptoms. Often symptoms do not worsen significantly. Research notes that esophagus-related chest pain sometimes results in emergency-room visits for fear of heart attack. Esophageal problems resulting from scleroderma or diabetes can be part of a range of greater complications associated with those conditions.

Recovery

People with esophageal motility disorders might benefit from the following:
  • Eating smaller meals
  • Eating dinner earlier, to give food a better chance to reach the stomach before bedtime
  • Sleeping on an incline, with the head of the bed raised
  • Losing weight, if the patient is obese
  • Diminishing, or abstaining from, alcohol consumption
  • Seeking psychiatric care, if the patient has a history of anxiety or depression

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