Motility disorders Flashcards
What are motility disorders of oesophagus
- Abnormal peristalsis
- Present with difficulty swallowing usually solids and liquids
- Less common than inflammatory or malignancy of oesophagus
Anatomy of oesophagus - part and type of muscle
- Upper 1/3 - skeletal muscle
- Middle 1/3 - transition zone of both skeletal and smooth muscle
- Lower 1/3 - smooth muscle
What is LOS vs UOS composed of?
- UOS - skeletal
- LOS - smooth muscle
What initiates oesophageal motion?
- Oesophageal myenteric neurones control peristaltic waves
- Primary wave under control of swallowing centre, secondary wave in response to distension
What happens as food moves down oesophagus?
LOS relaxes and allows food to pass into stomach
What is achalasia?
- Primary motility disorder
- Failure of relaxation of LOS and absence of peristalsis along oesophageal body
- Underlying cause though to be progressive destruction of ganglion cells in myenteric plexus
Risk with achalasia
- Increased risk of oesophageal cancer by 8-16x
- Absolute risk remains low though
Symptoms of achalasia
- Progressive dysphagia solids and liquids
- Regurgitation of food
- Symptom severity varies day to day
- Others can be respiratory complications eg nocturnal cough, aspiration, chest pain, dyspepsia, weight loss
Examination findings for achalasia
- Rarely any signs
- Visible weight loss - secondary to reduced oral intake
Investigations for motility disorder presentation
- Anyone with dysphagia - upper GI endoscopy - if severe can be dilated oesophagus with retained food and increased resistance GOJ
- Oesophageal manometry = gold standard
What is oesophageal manometry
- Pressure sensitive probe into oesophagus (5cm proximal to LOS)
- Measures pressure of sphincter and surrounding muscle
3 key features on manometry of achalasia
- Absence of oesophageal peristalsis
- Failure of relaxation of LOS
- High resting LOS tone
Classification of achalasia
- Chicago classification
- Based on contractility pattern in oesophageal body
Chicago classification
- Type I - classical achalasia, 100% failed peristalsis, LOS fails to relax completely
- II - pan-oesophageal pressuriation to >30mmHg in 20% of swallows at least, no normal peristalsis
- III - no normal peristalsis, preserved fragments of distal peristalsis OR premature contractions in more than 20% of swallows
Conservative management achalasia
- Sleeping with multiple pillows - reduce regurgitation
- Eating slowly
- Chewing food thoroughly
- Plenty of fluid with meals
Pharmacological options for achalasia
- CCBs - typically subligual Nifedipine to inhibit LOS contraction BUT benefit short lived
- Botox injections into LOS via endoscopy can be trialled, effects only last few months though
Surgical options for achalasia
- Laparascopic Heller Myotomy (cardiomyotomy)
- Per oral endoscopic myotomy (POEM)
- Endoscopic balloon dilatation
Laparascopic heller myotomy (cardiomyotomy)
- Division of specific fibres of LOS which fail to relax
- Only divide muscle fibres and avoid mucosal breach
Per oral endoscopic myotomy
- Cardiomyotomy at LOS performed from inside lumen of oesophagus - through a submucosal tunnel
- Post op rates of GORD are high though but good clinical response
Laparascopic heller myotomy vs other approaches
- Long term swallowing improvement in 85%
- Lower side effects than endoscopic
- Reflux becomes a problem after so partial fundoplication usually done at same time
Endoscopic balloon dilatation
- Insertion of balloon into LOS which is dilated to stretch muscle fibres
- Good response initially but risk of perforation and need for further intervention later
Management of end stage refractory achalasia
- May need oesophagectomy eventually
- If unsuitable, cardioplasty (cutting out LOS and anastomosing) may be done
What is diffuse oesophageal spasm?
- Multi-focal high amplitude contractions of oesophagus
- Dysfunction of oesophagus inhibitory nerves
- Sometimes can progress to achalasia
Symptoms of diffuse oesophageal spasm
- Severe dysphagia - solids and liquids
- Central chest pain - exacerbated by food
- Pain can respond to nitrates - due to relaxation of muscle, making if difficult to distinguish from angina
Examination diffuse oesophageal spasm
normal - like achalasia
Investigations for DOS
- Need upper GI endoscopy first - like any dysphagia
- Then definitve diagnosis via manometry
- Barium swallow less commonly used but can reveal corkscrew appearance
Manometry findings for diffuse oesophageal spasm
- Repetitive, simultaneous contractions of oesophagus
- Concurrent dysfunction of LOS
Management diffuse oesophageal spasm
- CCB - relax smooth muscle in oesophagus
- Pneumatic dilation or Heller myotomy if refractory
Other causes of dysmotility
- Autoimmune and CTD disorders
- eg systemic sclerosis (most common), polymyositis and dermatomyositis
- Managed via treating underlying disease, nutritional modification and PPIs as needed
