Download PDF
CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2021; 12(04): 196-201
DOI: 10.1055/s-0041-1741064
Review Article

Esophageal Motility Disorders: Are We Missing in Our Busy Endoscopy Practice?

Anshuman Elhence 
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Uday C. Ghoshal
1   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Esophageal motility disorders (EMDs) form a significant part of a busy endoscopist's practice. Endoscopy plays an all-encompassing role in the diagnosis and management of EMDs including achalasia cardia. The focus on in-vogue third-space endoscopic procedures such as per-oral endoscopic myotomy often digresses the important role of endoscopy. Endoscopic evaluation forms the part of standard first-line evaluation of any dysphagia and serves to rule out a secondary cause such as an esophagogastric junction malignancy and eosinophilic esophagitis. Moreover, endoscopic evaluation may itself provide corroborative evidence that may contribute to the diagnosis of the motility disorder. Achalasia cardia may present with a wide spectrum of endoscopic findings from being entirely normal and the well-known and pathognomonic dilated sigmoid-shaped esophagus with food residue, to lesser-known ornate signs. The evidence on the role of endosonography in EMDs is conflicting and largely restricted to evaluation of pseudoachalasia. High-resolution manometry (HRM) remains the gold standard in the diagnosis of EMDs. Endoscopists must also keep abreast of the latest iteration of the Chicago classification version 4.0, which differs significantly from its predecessor in being more stringent in making diagnosis of esophagogastric junction outflow obstruction and disorders of peristalsis since these manometric findings may be seen in normal individuals and may be mimicked by opioid use and gastroesophageal reflux. The latest rendition also includes the use of provocative maneuvers and testing in both supine and sitting posture. Despite being the gold standard, there are certain lacunae in the use and interpretation of the Chicago classification of which the users should be well aware. Emerging technologies such as functional lumen imaging probe and planimetry, and timed barium esophagogram fill the lacuna in diagnosis of these motility disorders, which at times is beyond the resolution of HRM.

Keywords

achalasia cardia - motor dysphagia - Chicago classification - hypercontractile esophagus - distal esophageal spasm - esophagogastric junction obstruction


Publication History

Article published online:
15 January 2022

© 2022. Society of Gastrointestinal Endoscopy of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Goenka MK, Afzalpurkar S, Ghoshal UC, Guda N, Reddy N. Impact of COVID-19 on gastrointestinal endoscopy practice in India: a cross-sectional study. Endosc Int Open 2020; 8 (07) E974-E979
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Yadlapati R, Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. What is new in Chicago Classification version 4.0?. Neurogastroenterol Motil 2021; 33 (01) e14053
    CrossrefPubMedGoogle Scholar
  • 3 DeLay K, Yadlapati R, Pandolfino JE. Chicago classification of esophageal motility disorders: past, present, and future. Indian J Gastroenterol 2021; 40 (02) 120-130
    CrossrefPubMedGoogle Scholar
  • 4 Misra A, Chourasia D, Ghoshal UC. Manometric and symptomatic spectrum of motor dysphagia in a tertiary referral center in northern India. Indian J Gastroenterol 2010; 29 (01) 12-16
    CrossrefPubMedGoogle Scholar
  • 5 Goyal O, Bansal M, Sood A. Esophageal motility disorders-symptomatic and manometric spectrum in Punjab, northern India. Indian J Gastroenterol 2017; 36 (03) 202-208
    CrossrefPubMedGoogle Scholar
  • 6 Yadlapati R, Kahrilas PJ, Fox MR. et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0© . Neurogastroenterol Motil 2021; 33 (01) e14058
    CrossrefPubMedGoogle Scholar
  • 7 Barnett DR, Balalis GL, Myers JC, Devitt PG. Diagnosis and treatment of pseudoachalasia: how to catch the mimic [Internet]. Ann Esophagus 2020;3. Accessed August 17, 2021: https://aoe.amegroups.com/article/view/5382
    Google Scholar
  • 8 Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med 1987; 82 (03) 439-446
    CrossrefPubMedGoogle Scholar
  • 9 Weiss AH, Iorio N, Schey R. Esophageal motility in eosinophilic esophagitis. Rev Gastroenterol Mex 2015; 80 (03) 205-213
    CrossrefPubMedGoogle Scholar
  • 10 Spechler SJ, Konda V, Souza R. Can eosinophilic esophagitis cause achalasia and other esophageal motility disorders?. Am J Gastroenterol 2018; 113 (11) 1594-1599
    CrossrefPubMedGoogle Scholar
  • 11 Moawad F, Lake J, Maydonovitch C, Veerappan G, Bassett J, Wong R. Esophageal motility disorders are uncommon in eosinophilic esophagitis: 39. Am J Gastroenterol 2009; 104: S16-S17
    CrossrefGoogle Scholar
  • 12 Mathur A, Mundada K, Verma A, Agrawal V, Verma V, Ghoshal UC. Eosinophilic gastroenteritis presenting as achalasia cardia and responding to botulinum injection and therapy directed against eosinophilic esophagitis. Indian J Gastroenterol 2019; 38 (06) 554-556
    CrossrefPubMedGoogle Scholar
  • 13 Pandolfino JE, Gawron AJ. Achalasia: a systematic review. JAMA 2015; 313 (18) 1841-1852
    CrossrefPubMedGoogle Scholar
  • 14 Matsubara M, Manabe N, Ayaki M. et al. Clinical significance of esophagogastroduodenoscopy in patients with esophageal motility disorders. Dig Endosc 2021; 33 (05) 753-760
    CrossrefPubMedGoogle Scholar
  • 15 Kuribayashi S, Uraoka T. Can esophageal motility disorders be detected by esophagogastroduodenoscopy?. Dig Endosc 2021; 33 (05) 744-745
    CrossrefPubMedGoogle Scholar
  • 16 Iwakiri K, Hoshihara Y, Kawami N. et al. The appearance of rosette-like esophageal folds (“esophageal rosette”) in the lower esophagus after a deep inspiration is a characteristic endoscopic finding of primary achalasia. J Gastroenterol 2010; 45 (04) 422-425
    CrossrefPubMedGoogle Scholar
  • 17 Hoshikawa Y, Hoshino S, Kawami N. et al. Possible new endoscopic finding in patients with achalasia: “gingko leaf sign”. Esophagus 2020; 17 (02) 208-213
    CrossrefPubMedGoogle Scholar
  • 18 Minami H, Isomoto H, Miuma S. et al. New endoscopic indicator of esophageal achalasia: “pinstripe pattern”. PLoS One 2015; 10 (02) e0101833
    CrossrefPubMedGoogle Scholar
  • 19 Gomi K, Inoue H, Ikeda H. et al. New endoscopic classification of the cardiac orifice in esophageal achalasia: champagne glass sign. Dig Endosc 2016; 28 (06) 645-649
    CrossrefPubMedGoogle Scholar
  • 20 Kato T, Naiki T, Araki H, Nagaki M, Moriwaki H. Diffuse esophageal spasm. Gastrointest Endosc 2004; 60 (03) 428
    CrossrefPubMedGoogle Scholar
  • 21 Cameron AJ, Malcolm A, Prather CM, Phillips SF. Videoendoscopic diagnosis of esophageal motility disorders. Gastrointest Endosc 1999; 49 (01) 62-69
    CrossrefPubMedGoogle Scholar
  • 22 Krishnan K, Lin C-Y, Keswani R, Pandolfino JE, Kahrilas PJ, Komanduri S. Endoscopic ultrasound as an adjunctive evaluation in patients with esophageal motor disorders subtyped by high-resolution manometry. Neurogastroenterol Motil 2014; 26 (08) 1172-1178
    CrossrefPubMedGoogle Scholar
  • 23 Oumrani S, Barret M, Roseau G. et al. Do we need endoscopic ultrasonography for the workup of patients with esophageal motility disorder?. Clin Res Hepatol Gastroenterol 2019; 43 (05) 608-613
    CrossrefPubMedGoogle Scholar
  • 24 Devière J, Dunham F, Rickaert F, Bourgeois N, Cremer M. Endoscopic ultrasonography in achalasia. Gastroenterology 1989; 96 (04) 1210-1213
    CrossrefPubMedGoogle Scholar
  • 25 Ponsot P, Chaussade S, Palazzo L. et al. Endoscopic ultrasonography in achalasia. Gastroenterology 1990; 98 (01) 253
    CrossrefPubMedGoogle Scholar
  • 26 Ata-Lawenko RM, Lee YY. Emerging roles of the endolumenal functional lumen imaging probe in gastrointestinal motility disorders. J Neurogastroenterol Motil 2017; 23 (02) 164-170
    CrossrefPubMedGoogle Scholar
  • 27 Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the clinical practice updates committee of the AGA institute. Clin Gastroenterol Hepatol 2017; 15 (03) 325-334
    CrossrefPubMedGoogle Scholar
  • 28 Donnan EN, Pandolfino JE. EndoFLIP in the esophagus: assessing sphincter function, wall stiffness, and motility to guide treatment. Gastroenterol Clin North Am 2020; 49 (03) 427-435
    CrossrefPubMedGoogle Scholar
  • 29 Campagna RAJ, Carlson DA, Hungness ES. et al. Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia. Surg Endosc 2020; 34 (06) 2593-2600
    CrossrefPubMedGoogle Scholar
  • 30 Wu PI, Szczesniak MM, Craig PI. et al. Novel intra-procedural distensibility measurement accurately predicts immediate outcome of pneumatic dilatation for idiopathic achalasia. Am J Gastroenterol 2018; 113 (02) 205-212
    CrossrefPubMedGoogle Scholar
  • 31 Neyaz Z, Gupta M, Ghoshal UC. How to perform and interpret timed barium esophagogram. J Neurogastroenterol Motil 2013; 19 (02) 251-256
    CrossrefPubMedGoogle Scholar
  • 32 Vaezi MF, Baker ME, Richter JE. Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram. Am J Gastroenterol 1999; 94 (07) 1802-1807
    CrossrefPubMedGoogle Scholar