Oesophagus Motor Disorders

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Oesophageal motor disorders are a group of conditions characterised by abnormal movement (motility) of the oesophagus, leading to difficulty swallowing, chest pain, and reflux-like symptoms.

Aetiology

• Achalasia: loss of peristalsis and failure of the lower oesophageal sphincter (LOS) to relax.
• Diffuse oesophageal spasm (DES): uncoordinated oesophageal contractions leading to chest pain and dysphagia.
• Hypercontractile oesophagus (Jackhammer oesophagus): excessively strong contractions causing severe pain.
• Hypomotility disorders: weak or absent peristalsis, often seen in systemic conditions like scleroderma.

Pathophysiology

• Disruption of normal oesophageal peristalsis due to neuromuscular dysfunction.
• Failure of the lower oesophageal sphincter to relax (achalasia) or excessive contraction (jackhammer oesophagus).
• Loss of oesophageal coordination leading to inefficient bolus transit.

Risk factors

• Neurological conditions (e.g., Parkinson’s disease).
• Autoimmune diseases (e.g., scleroderma).
• Chagas disease (leading to secondary achalasia).
• Age (more common in middle-aged and older adults).

Signs and symptoms

Symptoms:

• Difficulty swallowing (dysphagia) for both solids and liquids.
• Retrosternal chest pain (often non-cardiac in origin).
• Regurgitation of undigested food.
• Heartburn or reflux-like symptoms.
• Unintentional weight loss in severe cases.

Signs:

• Generally, no significant findings on physical examination.
• Malnutrition or weight loss in chronic cases.

Investigations

• Oesophageal manometry (gold standard): measures oesophageal motility and LOS function.
• Barium swallow: identifies delayed oesophageal emptying and bird’s beak appearance in achalasia.
• Upper GI endoscopy: rules out mechanical obstruction or malignancy.
• pH monitoring: assesses for gastro-oesophageal reflux disease (GORD) if reflux symptoms are present.

Management

1. Achalasia (specialist treatment):

• Pneumatic balloon dilation: endoscopic stretching of the lower oesophageal sphincter.
• Surgical myotomy (Heller’s myotomy): incision of the LOS to relieve obstruction.
• Botulinum toxin injection: temporary relief for patients unsuitable for surgery.
• Calcium channel blockers or nitrates: reduce LOS pressure in mild cases.

2. Diffuse Oesophageal Spasm and Jackhammer Oesophagus (specialist treatment):

• Calcium channel blockers (e.g., diltiazem): to relax oesophageal muscles.
• Proton pump inhibitors (PPIs): if GORD is a contributing factor.
• Low-dose tricyclic antidepressants (TCAs): reduce oesophageal hypersensitivity and pain.

3. Hypomotility Disorders (specialist treatment):

• Prokinetics (e.g., domperidone): to improve oesophageal emptying.
• Optimising management of underlying conditions: such as scleroderma.

Referral

• Gastroenterology referral for oesophageal manometry and further assessment.
• Upper GI surgical team referral for myotomy in severe achalasia.
• Neurology referral if a neurological disorder is suspected.