Advances in Management of Esophageal Motility Disorders

Abstract

The widespread adoption of high-resolution manometry (HRM) has led to a restructuring in the classification of esophageal motility disorder classification summarized in the Chicago Classification, currently in version 3.0. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or even with preserved peristalsis. Furthermore, despite these advances in diagnostics, no single manometric pattern is perfectly sensitive or specific for idiopathic achalasia and complimentary assessments with provocative maneuvers during HRM or interrogating the esophagogastric junction with the functional luminal imaging probe during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. Using these tools, we have come to conceptualize esophageal motility disorders as characterized by obstructive physiology at the esophagogastric junction, smooth muscle esophagus, or both. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. Now and going forward, optimal management is to render treatment in a phenotype-specific manner: e.g. POEM calibrated to patient-specific physiology for spastic achalasia and spastic disorders of the smooth muscle esophagus, more conservative strategies (pneumatic dilation) for the disorders limited to the sphincter.

Keywords: Dysphagia; Esophageal Motility Disorders; Esophagus; High-Resolution Manometry.

Figure 1.

Contractile and obstructing features of major esophageal motility disorders.

Figure 2.

Two images of FLIP Panometry showing repetitive antegrade cotractions (left) and repetitive retrograde contractions (right). The plots on top indicate the volume within the FLIP balloon (blue) and the corresponding pressure (red). On the topography plots time is on the x-axis, position along the 16 cm balloon on the y-axis, and spectral color indicates luminal diameter at each coordinate as per the scale. With the exception of the small blackened are on the first contraction in the left panel and the EGJ in the right panel, these are all non lumen-occluding contractions. Repetitive antegrade contractions are a normal finding and the patient on the left had normal motility on HRM. However, repetitive retrograde contractions are rarely found in normals and are usually indicative of obstructive physiology; the patient on the right had type III achalasia. The esophagogastric junction distensibility index (EGJ-DI) is measured at 60 ml distension with 2.8 mm²/mmHg being the lower limit of normal.