Pts may have a spectrum of manometric findings ranging from nonspecific abnormalities to defined clinical entities.
Motor obstruction caused by hypertensive lower esophageal sphincter (LES), incomplete relaxation of LES, or loss of peristalsis in smooth-muscle portion of esophagus. Causes include the following: primary (idiopathic) or secondary due to Chagas' disease, lymphoma, carcinoma, chronic idiopathic intestinal pseudoobstruction, ischemia, neurotropic viruses, drugs, toxins, radiation therapy, postvagotomy.
Chest x-ray shows absence of gastric air bubble. Barium swallow shows dilated esophagus with distal beaklike narrowing and air-fluid level. Endoscopy is done to rule out cancer, particularly in persons >50 years. Manometry shows normal or elevated LES pressure, decreased LES relaxation, absent peristalsis.
| TREATMENT | ||
AchalasiaPneumatic balloon dilatation is effective in 85%, with 3-5% risk of perforation or bleeding. Injection of botulinum toxin at endoscopy to relax LES is safe and effective in two-thirds of pts, but effects last 6-12 months. Myotomy of LES (Heller procedure) is effective, but 10-30% of pts develop gastroesophageal reflux. Nifedipine, 10-20 mg, or isosorbide dinitrate, 5-10 mg SL ac, may avert need for dilation or surgery. Sildenafil may also augment swallow-induced relaxation of the LES. |
Diffuse esophageal spasm involves multiple spontaneous and swallow-induced contractions of the esophageal body that are of simultaneous onset and long duration and are recurrent. Causes include the following: primary (idiopathic) or secondary due to gastroesophageal reflux disease, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia, or collagen vascular disease.
An important variant is nutcracker esophagus: high-amplitude (>180 mmHg) peristaltic contractions; particularly associated with chest pain or dysphagia, but correlation between symptoms and manometry is inconsistent. Condition may resolve over time or evolve into diffuse spasm; associated with increased frequency of depression, anxiety, and somatization.
Barium swallow shows corkscrew esophagus, pseudodiverticula, and diffuse spasm. Manometry shows spasm with multiple simultaneous esophageal contractions of high amplitude and long duration. In nutcracker esophagus, the contractions are peristaltic and of high amplitude. If heart disease has been ruled out, edrophonium, ergonovine, or bethanechol can be used to provoke spasm.
| TREATMENT | ||
Spastic DisordersAnticholinergics are usually of limited value; nitrates (isosorbide dinitrate, 5-10 mg PO ac) and calcium antagonists (nifedipine, 10-20 mg PO ac) are more effective. Those refractory to medical management may benefit from balloon dilation. Rare pts require surgical intervention: longitudinal myotomy of esophageal circular muscle. Treatment of concomitant depression or other psychological disturbance may help. |
Atrophy of the esophageal smooth muscle and fibrosis can make the esophagus aperistaltic and lead to an incompetent LES with attendant reflux esophagitis and stricture. Treatment of gastroesophageal reflux disease is discussed in Chap. 40 Nausea, Vomiting, and Indigestion.