Disorders of Esophageal Motility

Question 1

What is the most common site for esophageal diverticula?

Answer 1

Cervical esophagus

Question 2

What causes pulsion diverticula to develop?

Answer 2

A motility abnormality found distal to diverticula

Question 3

Are pulsion or traction forces the most common cause of esophageal diverticula?

Answer 3

Pulsion

Question 4

What is a Zenker diverticulum?

Answer 4

A pulsion diverticula secondary to a dysfunctional cricopharyngeus muscle - this results in herniation of esophageal mucosa through weak points within the pharyngeal musculature.

Question 5

What is the necessary surgical treatment for Zenker’s diverticula?

Answer 5

Esophageal myotomy must be performed, with diverticulectomy or diverticulopexy because of the underlying cricopharyngeal muscle dysfunction.

Question 6

What is the best imaging study to evaluate esophageal diverticula?

Answer 6

Barium swallow and video swallow

Question 7

What is the role of manometry in Zenker’s diverticulum?

Answer 7

None, however in mid or distal esophageal diverticula, it should be used to assess abnormalities of esophageal motility.

Question 8

What conditions contribute to cricopharyngeus muscle dysfunction?

Answer 8

Neurological damage (eg after stroke/trauma), cervical spine injuries after procedures, scarring or fibrosis, and radiation therapy.

Question 9

What is the preferred (traditional) procedure for Zenker’s diverticulum?

Answer 9

Cervical cricopharyngeal myotomy, and diverticulectomy or diverticulopexy

Question 10

What is the clinical presentation of diffuse esophageal spasm?

Answer 10

Patients typically present with substernal chest pain and dysphagia.

Question 11

How does diffuse esophageal spasm (DES) differ from achalasia?

Answer 11

Esophageal motility studies show that 20% of contractions are simultaneous, not peristaltic (compared to up to 100% in achalasia); LES is normal (not true for achalasia)

Question 12

What disease process should be ruled out in a patient with substernal chest pain and dysphagia?

Answer 12

Rule out cardiac etiology and GERD (with pH monitoring)

Question 13

What is the surgical intervention for diffuse esophageal spasm (DES)?

Answer 13

Esophageal myotomy

Question 14

What are the motility findings for nutcracker esophagus?

Answer 14

Esophageal contractions >180mm Hg, and normal or high pressure LES

Question 15

What are the esophageal motility findings typically associated with connective tissue disorders?

Answer 15

Weak or absent LES, with weak or absent distal contractions

Question 16

What symptoms are usually associated with esophageal dysmotility due to connective tissue disorders?

Answer 16

GERD like symptoms

Question 17

What is the workup and management of nutcracker esophagus?

Answer 17

Generally work up begins with ruling out cardiac causes, then focused GERD evaluation. If reflux precipitates the pain, acid suppression has good improvement in symptoms.

Question 18

What are the outcomes for surgical repair of nutcracker esophagus?

Answer 18

Very poor. Myotomy should rarely be performed in these patients.

Question 19

Which disease processes are common causes of connective tissue etiology of esophageal disorders?

Answer 19

Scleroderma and Systemic lupus erythematosus (SLE)

Question 20

What is the pathophysiology of esophageal disorders secondary to connective tissue disease?

Answer 20

Weakening of the smooth muscle with no detection of LES, and no contraction of distal esophagus.

Question 21

Why should patients with connective tissue disorders have aggressive treatment of GERD or reflux symptoms?

Answer 21

To prevent distal esophageal stricture formation

Question 22

In patients with scleroderma, why is a partial fundoplication preferred to a complete for treatment of severe and persistent reflux symptoms?

Answer 22

Because an incomplete wrap is less likely to combine with the weak esophageal contractions to cause dysphagia than a complete (and more obstructive wrap e.g Nissen)

Question 23

Why is a partial fundoplication often included in the surgical treatment of diffuse esophageal spasms (DES)?

Answer 23

Most patients with DES have a normal LES, and a a myotomy may result in poor esophageal emptying, and increase incidence of postoperative GERD.

Question 24

How is achalasia defined clinically?

Answer 24

Aperistalsis of body of esophagus and incomplete relaxation of the LES (low esophageal sphincter).

Question 25

What manometry findings are typical of achalasia?

Answer 25

Hypertensive LES

Question 26

How does achalasia present?

Answer 26

With chest pain, regurgitation and progressive dysphagia (liquids, then solids)

Question 27

A barium swallow in a patient with achalasia will show what?

Answer 27

A birds beak abnormality - incomplete relaxation of the LES and nonperistaltic contractions.

Question 28

When evaluating a patient suspected of achalasia, what should be included in the workup?

Answer 28

Manometry to assess LES, and motility, barium swallow to assess, and endoscopy to assess for proximal gastric mass.

Question 29

Name the treatment options for a patient with achalasia?

Answer 29

Medical treatment (isosorbide nitrite/calcium channel blockers), botox injections, pneumatic dilation, surgical myotomy

Question 30

What are the manometry findings for DES (diffuse esophageal spasms)?

Answer 30

Nonperistaltic contractions, and tertiary contractions

Question 31

What is a hypertensive lower esophageal sphincter?

Answer 31

LES pressure greater than 95th percentile, manometry shows normal relaxation of LES