Disorders of Esophageal Motility Flashcards
What is the most common site for esophageal diverticula?
Cervical esophagus
What causes pulsion diverticula to develop?
A motility abnormality found distal to diverticula
Are pulsion or traction forces the most common cause of esophageal diverticula?
Pulsion
What is a Zenker diverticulum?
A pulsion diverticula secondary to a dysfunctional cricopharyngeus muscle - this results in herniation of esophageal mucosa through weak points within the pharyngeal musculature.
What is the necessary surgical treatment for Zenker’s diverticula?
Esophageal myotomy must be performed, with diverticulectomy or diverticulopexy because of the underlying cricopharyngeal muscle dysfunction.
What is the best imaging study to evaluate esophageal diverticula?
Barium swallow and video swallow
What is the role of manometry in Zenker’s diverticulum?
None, however in mid or distal esophageal diverticula, it should be used to assess abnormalities of esophageal motility.
What conditions contribute to cricopharyngeus muscle dysfunction?
Neurological damage (eg after stroke/trauma), cervical spine injuries after procedures, scarring or fibrosis, and radiation therapy.
What is the preferred (traditional) procedure for Zenker’s diverticulum?
Cervical cricopharyngeal myotomy, and diverticulectomy or diverticulopexy
What is the clinical presentation of diffuse esophageal spasm?
Patients typically present with substernal chest pain and dysphagia.
How does diffuse esophageal spasm (DES) differ from achalasia?
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)
What disease process should be ruled out in a patient with substernal chest pain and dysphagia?
Rule out cardiac etiology and GERD (with pH monitoring)
What is the surgical intervention for diffuse esophageal spasm (DES)?
Esophageal myotomy
What are the motility findings for nutcracker esophagus?
Esophageal contractions >180mm Hg, and normal or high pressure LES
What are the esophageal motility findings typically associated with connective tissue disorders?
Weak or absent LES, with weak or absent distal contractions
What symptoms are usually associated with esophageal dysmotility due to connective tissue disorders?
GERD like symptoms
What is the workup and management of nutcracker esophagus?
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.
What are the outcomes for surgical repair of nutcracker esophagus?
Very poor. Myotomy should rarely be performed in these patients.
Which disease processes are common causes of connective tissue etiology of esophageal disorders?
Scleroderma and Systemic lupus erythematosus (SLE)
What is the pathophysiology of esophageal disorders secondary to connective tissue disease?
Weakening of the smooth muscle with no detection of LES, and no contraction of distal esophagus.
Why should patients with connective tissue disorders have aggressive treatment of GERD or reflux symptoms?
To prevent distal esophageal stricture formation
In patients with scleroderma, why is a partial fundoplication preferred to a complete for treatment of severe and persistent reflux symptoms?
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)
Why is a partial fundoplication often included in the surgical treatment of diffuse esophageal spasms (DES)?
Most patients with DES have a normal LES, and a a myotomy may result in poor esophageal emptying, and increase incidence of postoperative GERD.
How is achalasia defined clinically?
Aperistalsis of body of esophagus and incomplete relaxation of the LES (low esophageal sphincter).
What manometry findings are typical of achalasia?
Hypertensive LES
How does achalasia present?
With chest pain, regurgitation and progressive dysphagia (liquids, then solids)
A barium swallow in a patient with achalasia will show what?
A birds beak abnormality - incomplete relaxation of the LES and nonperistaltic contractions.
When evaluating a patient suspected of achalasia, what should be included in the workup?
Manometry to assess LES, and motility, barium swallow to assess, and endoscopy to assess for proximal gastric mass.
Name the treatment options for a patient with achalasia?
Medical treatment (isosorbide nitrite/calcium channel blockers), botox injections, pneumatic dilation, surgical myotomy
What are the manometry findings for DES (diffuse esophageal spasms)?
Nonperistaltic contractions, and tertiary contractions
What is a hypertensive lower esophageal sphincter?
LES pressure greater than 95th percentile, manometry shows normal relaxation of LES
