Oesophageal Motility Disorders

Question 1

What are motility disorders

Answer 1

Group of conditions that are characterised by abnormalities in oesophageal peristalsis

Question 2

What are the two major causes of oesophageal dysmotility

Answer 2

Oesophageal achalasia

Diffuse oesophageal spasm

Question 3

What is the upper third of the oesophagus made up of

Answer 3

Skeletal muscle

Question 4

What is the middle third of the oesophagus made up of

Answer 4

This is called the transition zone, made up of skeletal and smooth muscle cells

Question 5

What is the lower third of the oesophagus made up of

Answer 5

Smooth muscle

Question 6

What is the UOS composed of and what is its function

Answer 6

Skeletal muscle

Prevents air entry into the GI tract

Question 7

What is the LOS composed of and what is its action

Answer 7

Smooth muscle

Prevents acid reflux from stomach into the oesophagus

Question 8

What is achalasia

Answer 8

Primary motility disorder of the oesophagus characterised by failure of relaxation of the LOS and progressive failure of contraction of the oesophageal smooth muscle

Question 9

What is the pathophysiology of achalasia

Answer 9

Poorly understood but thought to be due to progressive destruction of ganglion cells in the myenteric plexus leading to failure of relaxation of the LOS

Question 10

What is the clinical features of someone with achalasia

Answer 10

1. Progressive dysphagia with solids and liquids
2. Chest discomfort
3. Vomiting
4. Food regurgitation
5. Weight loss

Question 11

What are the differential diagnosis of Achalasia

Answer 11

Same as those for dysphagia

Question 12

How would you investigate achalasia

Answer 12

Achalasia presents with dysphagia therefore first a OGD must be performed to exclude cancer. Once excluded the gold standard is oesophageal manometry.

Question 13

What is oesophageal manometry

Answer 13

A pressure sensitive probe is inserted into the oesophagus which measures the pressure of the sphincter

Question 14

What are the three key features seen for achalasia on manometry

Answer 14

• absence of oesophageal peristalsis
• failure of the LOS to relax
• high resting LOS tone

Question 15

What is the conservative treatment for Achalasia

Answer 15

1. Sleeping with many pillows to minimise regurgitation
2. Eating slowly
3. Drinking plenty of fluids with meals
4. CCBs/nitrates can give partial relief
5. Botox injections

Question 16

What are the surgical management options for achalasia

Answer 16

Endoscopic balloon dilation - insertion of balloon into the LOS which is inflated and dilates the LOS

Laparoscopic heller myotomy - division of muscle fibres in the LOS

Question 17

There is a increase in which type of cancer for patients with long standing Achalasia

Answer 17

Oesophageal cancer

Question 18

What is diffuse oesophageal spasm

Answer 18

A disease characterised bu multi-focal high amplitude contractions of the oesophagus thought to be due to the dysfunction of the inhibitory nerves of the oesophagus.
DOS can progress to achalasia

Question 19

What are the clinical features of diffuse Oesophageal spasm

Answer 19

• > severe dysphagia to solids and liquids
• > central chest pain exacerbated by food
• > chest pain relived by nitrates making it hard to distinguish between angina

Question 20

What would you see in a patient with DOS on barium swallow test

Answer 20

Cork screw appearance

Question 21

What is the gold standard investigation for diffuse oesophageal spasm

Answer 21

Oesophageal manometry which shows repetitive, simultaneous, and ineffective contractions of the oesophagus.

Question 22

What is the first line management of diffuse oesophageal spasm.

Answer 22

Nitrates

CCBS

Question 23

What is the treatment for patients with DOS and hypertension of the LOS

Answer 23

Pneumatic dilation