Oesophagus Motor Disorders

Gastroenterology (12%) Core Clinical Conditions

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Definition Aetiology Pathophysiology Sign and Symptoms Investigations Management

Esophageal motor disorders refer to a group of conditions that affect the normal functioning of the oesophagus, the muscular tube that carries food and liquid from the throat to the stomach. These disorders disrupt the coordinated muscle contractions necessary for the proper movement of swallowed contents down the oesophagus. As a result, individuals with esophageal motor disorders may experience difficulties in swallowing, regurgitation, chest pain, and other symptoms related to impaired esophageal motility.

1. Idiopathic: In some cases, the exact cause of esophageal motor disorders remains unknown, leading to the term "idiopathic." Idiopathic disorders suggest that there may be underlying factors contributing to the dysfunction, but they have not yet been identified.

2. Neurological Disorders: Certain neurological conditions can result in esophageal motor disorders. These may include Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), stroke, and spinal cord injuries. The disruption of nerve signals from the brain to the oesophagus can lead to impaired muscle activity and coordination.

3. Connective Tissue Disorders: Disorders affecting connective tissues within the body, such as scleroderma or Ehlers-Danlos syndrome, can also contribute to esophageal motor disorders. These conditions can cause abnormalities in the muscles and tissues of the oesophagus, leading to impaired motility.

4. Gastro-oesophageal reflux disease (GORD): Chronic acid reflux, commonly known as GORD, is another risk factor for esophageal motor disorders. The continuous backflow of stomach acid into the oesophagus can irritate and inflame the lining, leading to reduced muscle function and increased susceptibility to motor abnormalities.

5. Structural Anomalies: Abnormalities in the structure of the oesophagus or nearby organs may result in motor disorders. Conditions like a hiatal hernia, strictures, tumours, or abnormal growths can physically impede the proper movement of food and fluids through the oesophagus.

6. Medications: Certain medications can contribute to esophageal motor disorders. For example, long-term use of certain muscle relaxants or medications that affect nerve signalling, such as some antidepressants, antipsychotics, and anti-anxiety drugs, may disrupt normal oesophageal function.

7. Psychological Factors: Stress, anxiety, and psychological disorders, including eating disorders, can influence oesophagus motor function. These factors may lead to abnormal muscle contractions, thereby affecting the coordinated movement of the oesophagus during swallowing and digestion.

8. Ageing: The ageing process itself can contribute to esophageal motor disorders. As individuals grow older, the normal physiological changes in muscle tone and elasticity can impact the seamless functioning of the oesophagus, potentially leading to motor disorders.

1. Achalasia: Achalasia is characterised by the impairment of esophageal peristalsis and inadequate relaxation of the lower esophageal sphincter (LES). This is due to the degeneration or loss of the inhibitory neurons in the myenteric plexus of the esophageal wall. As a result, the LES fails to relax properly, leading to increased pressure and impaired passage of food from the oesophagus into the stomach.

2. Diffuse Esophageal Spasm: Diffuse esophageal spasm is characterised by uncoordinated contractions of the esophageal smooth muscles. The exact cause is unclear, but abnormal functioning of the nerves that control the esophageal muscles is considered a contributing factor. These abnormal contractions can result in irregular contraction patterns, high intra-esophageal pressures, and difficulty in propelling the food bolus.

3. Nutrafontinure: Nutcracker oesophagus is a condition characterised by abnormal high-amplitude contractions of the esophageal smooth muscles. The exact cause is unknown but may involve dysregulation of the nerves that control the esophageal muscles, leading to exaggerated contractions. These high-pressure contractions can cause chest pain and difficulty in swallowing.

4. Hypertensive Lower Esophageal Sphincter (LES): Hypertensive LES occurs when the lower esophageal sphincter muscle remains contracted for a prolonged period, resulting in increased resting pressure. The cause is not fully understood, but it may be related to abnormalities in the nerve signals that control the LES. The high resting pressure can impair the normal movement of food from the oesophagus into the stomach.

5. Gastro-oesophageal reflux disease (GORD): In GORD, the lower esophageal sphincter fails to close properly, allowing stomach acid and partially digested food to flow back into the oesophagus, leading to symptoms such as heartburn, regurgitation, and chest discomfort. The weak or dysfunctional LES can be due to various factors, including decreased resting pressure, hiatal hernia, and impaired esophageal clearance.

6. Scleroderma: Scleroderma is an autoimmune disorder characterised by the excessive production and deposition of collagen, leading to fibrosis of multiple organs, including the oesophagus. In the oesophagus, the fibrotic changes can cause a decrease in compliance, impaired peristalsis, and reduced LES relaxation, resulting in dysphagia, regurgitation, and heartburn.

7. Globus Pharyngeus: Globus pharyngeus is a sensation of a lump or foreign body in the throat, without an actual physical obstruction. Although the exact cause is not well understood, it is thought to be multifactorial, involving dysfunction of the muscles and nerves innervating the throat and oesophagus. Psychological factors, such as anxiety or stress, may also contribute to this condition.

1. Dysphagia: This is the most common symptom of esophageal motor disorders. Dysphagia refers to difficulty or discomfort in swallowing food or liquids. It may feel as if food is getting stuck in the throat or chest, and individuals may need to take smaller bites or chew more thoroughly to compensate.

2. Regurgitation: Esophageal motor disorders can cause regurgitation, which is the backflow of food or liquid from the stomach into the throat or mouth. Individuals may experience an unpleasant taste in their mouth or have a sensation of food coming back up shortly after eating.

3. Chest pain: Some people with esophageal motor disorders may experience chest pain or discomfort, which can be mistaken for cardiac-related issues like a heart attack. This pain is typically felt behind the breastbone and may worsen after meals or during swallowing.

4. Heartburn: Esophageal motor disorders can result in increased episodes of heartburn. This burning sensation in the chest is caused by stomach acid refluxing into the oesophagus. It may be triggered by certain foods, lying down after meals, or bending over.

5. Gastro-oesophageal reflux disease (GORD): GORD is a common complication of esophageal motor disorders. It occurs when stomach acid frequently flows back into the oesophagus, causing irritation and inflammation. Symptoms of GORD can include heartburn, regurgitation, and a sour taste in the mouth.

6. Weight loss: In severe cases, esophageal motor disorders can lead to weight loss due to difficulties in eating and swallowing. Persistent dysphagia or discomfort during meals can result in reduced food intake, leading to unintentional weight loss over time.

7. Coughing or choking: Individuals with esophageal motor disorders may experience coughing or choking episodes, particularly when drinking or eating. This can occur due to food or liquid entering the windpipe instead of passing into the oesophagus.

8. Feeling of a lump in the throat: Some individuals with esophageal motor disorders report a persistent feeling of a lump or something being stuck in the throat, known as globus sensation. This sensation can cause discomfort or the urge to swallow repeatedly.

1. Barium swallow test: This test involves fluoroscopy, where the patient consumes a liquid containing barium. X-ray images are then taken as the barium moves down the oesophagus. This test helps identify abnormalities in the oesophagus, such as narrowing, blockages, or muscle dysfunction.

2. Manometry: Esophageal manometry is considered the gold standard diagnostic tool for esophageal motor disorders. It measures the pressure and coordination of the muscle contractions in the oesophagus. This test helps diagnose conditions like achalasia, diffuse esophageal spasm, and other motility disorders.

3. Endoscopy: During an endoscopy, a flexible tube with a camera is inserted through the mouth and into the oesophagus. This allows the doctor to visualise the oesophagus, stomach, and upper part of the small intestine. Endoscopy can identify structural abnormalities, inflammation, or narrowing in the oesophagus.

4. Ambulatory pH monitoring: This test measures the amount of acid reflux or non-acidic content that moves up into the oesophagus. It involves placing a small catheter through the nose into the oesophagus, which measures pH levels over 24 to 48 hours. Ambulatory pH monitoring helps diagnose conditions like gastroesophageal reflux disease (GERD) and evaluates the effectiveness of treatment.

1. Lifestyle modifications: Encouraging lifestyle changes can help alleviate symptoms and improve esophageal function. Patients are advised to avoid foods and beverages that trigger symptoms such as spicy foods, fatty foods, caffeine, and alcohol. Eating smaller, more frequent meals and maintaining an upright position after eating can also be beneficial.
2. Dietary alterations: Modifying the diet can play a pivotal role in managing oesophagus motor disorders. In many cases, a soft or liquid diet may be recommended to reduce the strain on the esophagus and facilitate easier swallowing. Additionally, avoiding foods that are difficult to chew or swallow, such as tough meats or large chunks of food, can be helpful.
3. Medications: Various medications can be prescribed to manage symptoms and improve esophageal function. Proton pump inhibitors (PPIs) are commonly used to reduce acid reflux and alleviate heartburn.
4. Botulinum toxin injections: For certain esophageal motor disorders, such as achalasia, injecting botulinum toxin into the lower esophageal sphincter can help relax the muscle and improve food passage. This procedure is typically performed endoscopically and may provide temporary relief.
5. Surgical intervention: In some cases, surgical procedures may be necessary to manage oesophagus motor disorders. Fundoplication surgery can be performed to treat severe acid reflux by wrapping the upper part of the stomach around the lower esophagus, reinforcing the lower esophageal sphincter. Other surgical options include myotomy (surgical cutting of the muscles) for achalasia or esophageal diverticulectomy for diverticula.

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