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Non-achalasic motor disorders of the oesophagus

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Motor abnormalities of the oesophagus are characterised by a chronic impairment of the neuromuscular structures that co-ordinate oesophageal function. The best-defined entity is achalasia, which is discussed in a separate chapter. Other motor disorders with clinical relevance include diffuse oesophageal spasm, oesophageal dysmotility associated with scleroderma, and ineffective oesophageal motility. These non-achalasic motor disorders have variable prevalence but they could be associated with invalidating symptoms such as dysphagia, chest pain and gastro-oesophageal reflux disease. New oesophageal diagnostic techniques, including high-resolution manometry, high-frequency intraluminal ultrasound and intraluminal impedance, allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce normal or abnormal patterns of bolus transport. This chapter discusses recent advances in physiology, pathophysiology, diagnosis and treatment of non-achalasic oesophageal motor disorders.

Section snippets

Classification

Several classifications of oesophageal motor disorders are available, either based on standard manometric findings (Table 1)1 or a combination of manometric findings and pathophysiological interpretation (Table 2).2 Recent advances in oesophageal diagnostic techniques allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce

New techniques to assess oesophageal motor function

Classical techniques such as barium swallow radiography and standard oesophageal manometry are used routinely in clinical practice to evaluate patients with suspected oesophageal dysmotility. Although many patients can be diagnosed accurately with these techniques, non-obstructive dysphagia or chest pain cannot be attributed to clear radiological or manometric abnormalities in many other patients. High-resolution manometry (HRM) is a stationary method that uses an increased number of pressure

Diffuse oesophageal spasm

The concept of oesophageal spasm was introduced by Osgood9 based on six patients with episodic chest pain and dysphagia. DOS10 is defined by episodes of chest pain and/or dysphagia, and simultaneous contractions in standard oesophageal manometry (≥20% of wet swallows) interposed with normal peristalsis in the distal oesophagus11 and normal LOS relaxation. Recently, it has been proposed that this entity should be renamed ‘distal oesophageal spasm’ because most of the simultaneous contractions

Oesophageal involvement in scleroderma

Most connective tissue diseases may impair oesophageal motility, predominantly affecting either the smooth muscle (scleroderma) or the striated muscle (dermatopolymyositis) in the oesophagus. Severe oesophageal dysmotility is most frequently observed in scleroderma. The gastrointestinal tract is involved in up to 90% of patients with scleroderma, and the oesophagus is the most frequently affected organ. Serious complications related to oesophageal involvement can occur in 50% of patients with

Severe ineffective oesophageal motility

Ineffective oesophageal motility (IOM) designates a manometric pattern of peristaltic failure characterised by the presence of distal oesophageal contractions of very low amplitude (less than 30 mmHg) and/or non-transmitted proximal contractions. The definition of IOM is based on the concept that pressure waves in the distal oesophagus, with amplitudes lower than 30 mmHg, are associated with failure of bolus clearance measured either radiologically86 or scintigraphically.87 This manometric

Summary

Non-achalasic motor disorders have variable prevalence but they may be associated with invalidating symptoms such as dysphagia, chest pain and GORD. DOS has a low prevalence but is associated with chest pain and/or dysphagia. The oesophageal wall is thicker and there is a functional impairment of intrinsic inhibitory neurons and/or a possible subtle outlet obstruction. Symptoms may be due to prolonged contractions (circular and/or longitudinal muscle) inducing ischaemia or hypersensitivity. The

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