Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Abstract

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Keywords: Absent Contractility; Achalasia; Barium Esophagram; Distal Esophageal Spasm; Esophageal Motility Disorders; Esophagogastric Junction; FLIP; High-Resolution Manometry; Hypercontractile Esophagus; Ineffective Esophageal Motility.

Figure 1:

Manometric classification of various esophageal motility disorders based on Chicago Classification v4.0. HRIM (High resolution impedance manometry); IRP (Integrated relaxation pressure); DCI (distal contractile integral); DES (distal esophageal spasm); IEM (ineffective esophageal motility); TBE (timed barium esophagram); FLIP (functional luminal imaging probe).

Figure 2:

Treatment options in patients with achalasia.

Figure 3:

Treatment options in patients with disorders of esophageal peristalsis after a careful endoscopy is performed to rule out a mechanical or mucosal disease (such as eosinophilic esophagitis). *In patients with chest pain as the primary symptom, overlapping esophageal hypersensitivity might play a major role in symptom generation and neuromodulators or behavioral treatments might be beneficial based on studies on non-cardiac chest pain.

Figure 4:

Impact of mucosal diseases, opioids, and connective tissue disease on esophageal motility. Figure shows presence of various secondary motility abnormalities, and the triangle shape indicates visual approximations of the prevalence of those motility abnormalities with each disease state. Most patients will have a normal motility testing. For instance, in opioid induced esophageal dysfunction, there is higher prevalence of hypercontractile esophagus and distal esophageal compared to achalasia. On the other hand, majority of patients with GERD will have normal esophageal motility followed by hypomotility disorders and lower prevalence of distal esophageal spasm. DES (distal esophageal spasm); IEM (ineffective esophageal motility).