Oesophageal Motility Disorders

Two primary motor disorders of the oesophagus — achalasia and diffuse oesophageal spasm — both causing dysphagia and chest pain/discomfort, both diagnosed by manometry.

Achalasia

Characterised by degeneration of the ganglia of the nerves innervating the oesophagus; the cause is unclear. Cardinal features: lack of relaxation of the lower oesophageal sphincter, and aperistalsis of the oesophageal body — causing dysphagia, regurgitation, and chest discomfort or pain.

Diagnosis: confirmed by barium swallow or manometry — manometry is the only way to diagnose with certainty.

Management: aims to reduce the pressure in the lower oesophageal sphincter so food passage is no longer obstructed.

• Laparoscopic myotomy or balloon dilation — equally effective.
• Peroral endoscopic myotomy (POEM) — now an established, guideline-supported alternative to laparoscopic Heller myotomy and pneumatic dilation, with comparable efficacy and safety; specifically favoured for achalasia subtype III. A minimally invasive endoscopic technique (no external incisions), widely adopted since first performed in 2008.
• Botulinum toxin type A injection into four quadrants of the lower oesophageal sphincter — may need repeating every 3–12 months.
• Nitrates and calcium channel blockers — may be trialled for mild symptoms or patients unsuitable for other therapies (limited benefit, may cause cardiovascular and GI side effects).

Diffuse oesophageal spasm

Can cause dysphagia and regurgitation. A cause of noncardiac chest pain — cardiac disease should be excluded. May be precipitated or exacerbated by GORD.

Management: a trial of optimal GORD treatment may produce substantial improvement and should be used as initial therapy. Ingestion of warm water at the onset of an attack may be beneficial. If not effective, sublingual nitrates may shorten the attack:

• Glyceryl trinitrate spray 400 micrograms sublingually, as required.
• Glyceryl trinitrate tablet 600 micrograms sublingually, as required.

If episodes of spasm are frequent and disabling, consider a trial of one of the following:

• Diltiazem controlled-release 180mg orally once daily, increasing to 240 or 360mg once daily depending on response and adverse effects.
• Isosorbide dinitrate 10–20mg orally, 3–4 times daily.
• Nifedipine controlled-release 20–30mg orally once daily, increasing to 60mg once daily depending on response and adverse effects.

For refractory symptoms or frequent disabling episodes of distal oesophageal spasm, consider oesophageal manometry to confirm the diagnosis.