Esophageal motility disorders

Dr / Hytham Nafady

Types of esophageal contractionsEsophageal contractions

Primary

Propulsive

Secondary

Propulsive

Tertiary

Non propulsive

Esophageal motility disorders

Primary

Achalasia

Diffuse esophageal spasm

Nutcracker esoaphagus

Hypertensive LES

Secondary

GERD

Scleroderma

Chagas disease

Post-operative

Primary Esophageal motility disorders

Hypo-motility disorders

Achalasia

Hyper-motility disorders

Diffuse esophageal spasm

Nutcracker esophagus

Hypertensive LES

Esophageal manometry

Diffuse esophageal spasm

•Corkscrew esophagusBarium swallow

•Peristalsis:•> 30% repetitive tertiary contractions.

Video-fluoroscopy

•LES: •Occasionally hypertensive, occasionally incomplete relaxation.

Esophageal manometery

Nutcracker esophagus

•Normal.Barium swallow

•Peristalsis:•Hyper-peristalsis of distal esophagus.

Video-fluoroscopy

•LES: •Usually normal but occasionally hypertensive.

Esophageal manometery

Hypertensive LES

•Normal.Barium swallow

•Peristalsis:•Normal.

Video-fluoroscopy

•LES: •Resting pressure > 45 mm Hg

Esophageal manometery

Presby esophagus

• Abnormal esophageal motility in the elderly.• irrespective of the kind of motility disorder.• This includes:• Diffuse esophageal spasm.• Dilated esophagus with poor peristalsis.

Esophageal motility

disorders:

C.P: Barium swallow / vidofluroscopy:

Achalasia of the cardia:

Dysphagia.Regurgitation.

Dilated esophagus with smooth tapering of its lower end giving bird beaks appearance.

Diffuse esophageal spasm:

Dysphagia.Odenophagia.

Absent primary peristalsis.Repitive (>30%) tertiary non propulsive contractions giving cork screw appearance.

Presby esophagus:

Asymptomatic esophageal motility disorder in elderly.

Weak primary peristalsis.Tertiary contractions with cork screw esophagus.

Scleroderma:Atrophy of the smooth muscles with replacement by fibrous tissue.

Dysphagia.Reflux.

Dilated atonic lower 2/3 of the esophagus (smooth muscles).Normal motility of the upper 1/3 (striated muscles).Patulous lower esophageal sphincter with GERD.

Reflux esophagitis:

Dysphagia,Regurgitation,Heart burn.

Granular mucosal pattern.Shallow ulcers in the distal esophagus.Esophagogastric pseudopolyp.Transverse fixed mucosal folds (step ladder pattern).Buckering & sacculations.Feline esophagus.Peptic stricture.Barret esophagus.

Postoperative secondary diffuse esophageal spasm

• After laparscopic Nissen fundoplication.

Achalasia of the cardia

Definition

• Esophageal motility disorder characterized by hypo-peristalsis & incomplete relaxation of the lower esophageal sphincter.

Etiology

•Degeneration of the Aeurbach’s plexus.

1ry ACHALASIA

•Neoplastic.•Chagas disease.•Postoperative (laparoscopic Nissen fundoplication).

2ry ACHALASIA

C.P

• Long standing dysphagia > 1 year.• Regurgitation.

1RY ACHALASI

A

• Short duration dysphagia < 6 month.

• Odynophagia.

2RY ACHALASI

A

Demographics

Age:• 1ry achalasia: young patients (30-50 y).• 2ry achalasia: older patients (> 60 y).Gender: • M=F.

Complications

• Aspiration pneumonia.• Esophageal carcinoma.

Aspiration pneumonia

•Mediastinal widening, with double contour of mediastinal borders (outer border represent dilated esophagus).

•Mediastinal air fluid level.•Displacement of the azygo-esophageal recess.•Anterior bowing of the trachea.•Absent gastric air bubbles.

Chest PA

•Dilated esophagus•Early mild.•Later marked (sigmoid shaped).•Bird beak deformity (smooth tapering of the distal end of the esophagus).

Barium swallow

•Peristalsis:•Absent primary peristalsis.

Video-fluoroscopy

•LES: •incomplete relaxation.

Esophageal manometery

Azygoesophageal recess

Azygoesophageal recess

Displacement of the azygoesophageal recess

Dilated esophagus with bird beak deformity

DD

• 2ry achalasia (e.g esophageal carcinoma or Nissen fundoplication).

• Scleroderma.• Reflux esophagitis, with stricture.

Primary achalasia Secondary achalasia (pseudoachalasia)Markedly dilated esophagus (> 4 cm in its maximum diameter).

Mildly dilated esophagus (less than 4 cm in its maximum diameter).

Short narrow segment (< 3.5 cm) Long narrow segment (> 3.5 cm)

Eccentric narrowingAsymmetrical shoulderingMucosal nodularity.

2ry achalasia after Nissen fundoplication

Clips

Barrot beak appearance

Achalasia SclerodermaAperistaltic dilated esophagus.

Narrowed esophago-gastric junction.

Patulous esophago-gastric junction.

Achalasia Reflux esophagitis with stricture.

Smooth tapering of the distal esophageal segment.

Associated with aperistalsis. Associated with hiatus hernia.

Gross dilatation of the esophagus.

Rarely associated with gross dilatation.