Oesophageal motility disorders Flashcards
What disorders come under the category of oesophageal motility disorders?
Achalasia
Diffuse oesophageal spasm
Hypertensive peristalsis (Nutcracker oesophagus)
Systemic sclerosis
What is achalasia?
An oesophageal motility disorder characterised by oesophageal aperistalsis and impaired relaxation of the lower oesophageal sphincter.
At what ages does achalasia occur?
It occurs at all ages but is rare in childhood
Describe the clinical features of achalasia
Patients usually have a long history of intermittent dysphagia, characteristically for both liquids and solids from the onset.
Regurgitation of food from the dilated oesophagus occurs, particularly at night.
Spontaneous chest pain occurs, perhaps due to oesophageal spasm.
What are complications of achalasia?
Aspiration pneumonia
Slight increase in incidence of squamous carcinoma of the oesophagus
How can achalasia be investigated?
What do the investigations show?
CXR: shows a dilated oesophagus, sometimes with a fluid level seen behind the heart. The fundal gas shadow is absent
Barium swallow: shows lack of peristalsis and often synchronous contractions of the body of the oesophagus, sometimes with dilatation. The lower end shows a “bird’s beak” due to failure of the sphincter to relax.
Oesophagoscopy: performed to exclude a carcinoma at the lower end of the oesophagus, whcih can produce a similar X ray appearance. In true achalasia the endoscope passes through the lower oesophageal sphincter with little resistance.
CT scan: sometimes excludes lower oesophageal cancer.
Manometry: shows aperistalsis of the oesophagus and failure of relaxation of the lower oesophageal sphincter.
How is achalasia treated?
All current forms of treatment are palliative.
Endoscopic dilatation of the LOS using a hydrostatic balloon under X-ray control: weakens the sphincter. There is a low risk of perforation.
Intrasphincteric injection of botulinum toxin A: relaxes the sphincter.
Surgery: surgical division of the LOS, Heller’s operation.
Reflux oesophagitis complicates all of the procedures and the aperistalsis of the oesophagus remains.
How does systemic sclerosis affect the oesophagus?
There is diminished peristalsis and oesophageal clearance, due to the replacement of the smooth muscle by fibrous tissue
LOS pressure is decreased, allowing reflux with consequent mucosa damage
Strictures may develop
What are the symptoms of systemic sclerosis in the oesophagus?
Initially there are no symptoms, but dysphagia and heartburn occur as the oesophagus becomes more severely involved.
What is diffuse oesophageal spasm?
A severe form of oesophageal dysmotility that can sometimes produce retrosternal chest pain and dysphagia. It can accompany GORD.
Swallowing is accompanied by bizarre and marked contractions of the oesophagus without normal peristalsis.
How may the oesophagus look in diffuse oesophageal spasm on barium swallow?
The appearance may be that of a “corkscrew” oesophagus.
What is the nutcracker oesophagus/hypertensive peristalsis?
A variant of diffuse oesophageal spasm.
It is characterised by very high-amplitude peristalsis (pressure >200 mmHg) within the oesophagus. Chest pain is commoner than dysphagia.
What is the treatment for diffuse oesophageal spasm and hypertensive peristalsis?
PPIs may be used if reflux is a factor.
Antispasmodics, nitrates calcium-channel blockers and GABA receptor antagonistsare used.
Balloon dilatation or longitudinal oesophageal myotomy is occasionally necessary.
