Primary Esophageal Motor Disorder Research Articles

Hypertrophy of the lower-esophageal sphincter and esophageal muscularis propria in patients with primary esophageal motor disorders

Hypertrophy of the lower-esophageal sphincter and esophageal muscularis propria in patients with primary esophageal motor disorders

Nutcracker esophagus: clinical evaluation of 97 patients

Nutcracker esophagus is a manometric abnormality classified as a primary esophageal motor disorder, characterized by high pressure peristaltic waves in distal esophagus and related to non-cardiac chest pain. Further studies observed nutcracker esophagus in dysphagic patients and recently in gastroesophageal reflux disease. However, there is controversy about the meaning of this motor disorder and there are few clinical studies involving a great number of patients. A retrospective study involving 97 patients with manometric criteria of nutcracker esophagus according a control group was undertaken. Most of the patients were female (63.9%), mean age 54.3 years. The chief complaint was chest pain, followed by dysphagia and heartburn. Clinical findings, as a whole were chest pain (53.6%), dysphagia (52.6%), heartburn (52.6%), regurgitation (21.6%), otorhinolaryngologic symptoms (15.4%), dyspepsia (15.4%) and odynophagia (4.1%). The majority of patients had multiple symptoms, however in 28% just a single one was observed. Endoscopic examination observed erosive esophagitis in 8% of the patients, while signs of esophageal motor disorders were showed by esophagogram in 16.4%. Esophageal pH recordings indicated abnormal gastroesophageal reflux in 41.2% of the cases reported. We concluded that there are other symptoms in nutcracker esophagus patients besides chest pain and dysphagia and the use of esophageal pH recordings is helpful to establish its association with acid reflux and guide the appropriate therapy.

Review article: pharmacological options in achalasia.

Achalasia is a common primary oesophageal motor disorder. Treatment has been based traditionally on a surgical approach; however, there is new evidence that some medical strategies may be of benefit. The purpose of the present article was to review the current medical management of achalasia. A Medline search identified original articles and reviews published in the English-language literature between 1966 and 1998. This search has revealed that the pharmacological treatment of achalasia is limited to some subgroups of patients (for example, early stages of the disease and elderly patients), and that nitrates, nifedipine, and botulinum toxin are the best studied and most effective compounds.

The nutcracker esophagus: a late diagnostic yield notwithstanding chest pain and dysphagia.

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23-78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21-67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 +/- 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.

Clinical use of ambulatory 24-hour esophageal motility monitoring in patients with primary esophageal motor disorders.

The development of miniaturized electronic pressure transducers and portable digital data recorders with large storage capacity has made ambulatory monitoring of esophageal motor function over an entire circadian cycle possible. Broad clinical application of this new technology in a large number of asymptomatic normal volunteers and patients with symptoms suggestive of a primary esophageal motor disorder provides new insights into esophageal motor function under a variety of physiologic conditions in health and disease. These studies suggest that ambulatory esophageal motility monitoring allows for a more precise classification of esophageal motor disorders than standard manometry and can identify abnormal esophageal motor patterns associated with nonobstructive dysphagia or noncardiac chest pain. Ambulatory esophageal motility monitoring performed in combination with pH monitoring is currently the most physiologic way to assess esophageal function and has potential to improve diagnosis and management of patients with esophageal motor disorders. Ambulatory 24-h esophageal motility monitoring should become the gold standard for assessing motor function of the esophageal body.

Coping with achalasia.

Achalasia is a primary esophageal motor disorder that is characterized by dysphagia, regurgitation, and chest pain. The diagnosis is suggested by narrowing with the classic "bird's beak" appearance of the distal esophagus. Esophageal manometry showing aperistalsis confirms the diagnosis. Pseudo-achalasia must be excluded with endoscopy. Pneumatic dilatation is the treatment of choice. Surgical myotomy is reserved for patients in whom repeated pneumatic dilatation fails.

Indications, technique, and clinical use of ambulatory 24-hour esophageal motility monitoring in a surgical practice.

The development of miniaturized electronic pressure transducers and portable digital data recorders with large storage capacity has made ambulatory monitoring of esophageal motor function over an entire circadian cycle possible. The broad clinical application of this new technology in a large number of asymptomatic normal volunteers and patients with primary esophageal motor disorders or gastroesophageal reflux disease provides new insights into esophageal motor function in health and disease under a variety of physiologic conditions. In normal volunteers and symptomatic patients, esophageal motor activity increases with both the state of consciousness and eating activity, i.e., from sleep to awake to meal periods. In the normal situation there is a higher prevalence of nonperistaltic esophageal contractions than appreciated on stationary manometry. Compared with standard manometry, ambulatory esophageal manometry provides a more than 100-fold larger database for the classification and quantitation of abnormal esophageal motor function and leads to a change in the diagnosis in a substantial portion of patients with symptoms suggestive of a primary esophageal motor disorder. In patients with nonobstructive dysphagia, the circadian esophageal motility pattern is characterized by an inability to organize the motor activity into peristaltic contractions during meal periods. In patients with noncardiac chest pain, ambulatory motility monitoring can document a direct correlation of abnormal esophageal motor activity with the symptom and shows that the abnormal motor activity immediately preceding the pain episodes is characterized by an increased frequency of simultaneous, double- and triple-peaked, high-amplitude, and long-duration contractions. A long esophageal myotomy can abolish the ability of the esophagus to produce this abnormal motor pattern. In patients with gastroesophageal reflux disease, ambulatory motility monitoring shows that the contractility of the esophageal body deteriorates with increasing severity of esophageal mucosal injury, compromising the clearance function of the esophageal body. These data suggest that ambulatory esophageal motility monitoring allows for a more precise classification of esophageal motor disorders than standard manometry and can identify abnormal esophageal motor pattern associated with nonobstructive dysphagia, noncardiac chest pain, or gastroesophageal reflux. Ambulatory esophageal manometry therefore should replace standard manometry in the assessment of esophageal body function and has potential to improve the diagnosis and management of patients with esophageal motor abnormalities. The combination of ambulatory 24-hour esophageal manometry with esophageal and gastric pH monitoring is currently the most physiologic way to assess patients with functional foregut disorders.

Isolated Hypertensive Lower Esophageal Sphincter

The hypertensive lower esophageal sphincter is an infrequent primary esophageal motor disorder characterized by elevated mean lower esophageal sphincter pressure (greater than or equal to 3 SD from that of controls), sphincter relaxations greater than 75%, and normal peristaltic activity in the esophageal body. This disorder is frequently associated with the nutcracker esophagus. We report our clinical and manometric experience with the isolated hypertensive lower esophageal sphincter (i.e., unassociated with other motor disorders), which constituted 2.7% of all patients who complained of dysphagia or chest pain referred for manometry during the period from October 1982 to February 1991.

Esophageal motility, heartburn, and gastroesophageal reflux: Variations in clinical presentation of esophageal dysphagia

Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.

Esophageal Motor Disorders

Primary esophageal motor disorders are rare, but they respond well to surgery if they are accurately diagnosed and if treatment carefully follows the fundamental principles of management. In the lower esophagus the most important primary disorders are achalasia, diffuse esophageal spasm, and scleroderma. Upper esophageal primary disorders are mostly rare; however, problems of age and neurologic diseases are a significant source of debility, making their management important. Details of investigation and management have been outlined in this article.