Other oesophageal motility disorders

Other oesophageal motility disorders

Hypercontractile motility disorders Distal oesophageal spasm is a condition in which there are incoordinate, premature and rapidly propagated contractions of the oesophagus, causing dysphagia and/or chest pain. The condition may be dramatic, with marked hypertrophy of the circular muscle and a corkscrew oesophagus on the barium oesophagogram ( Figure 66.29 ). These abnor mal contractions are more common in the distal two-thirds of the oesophageal body . Hypercontractile (jackhammer) oesophagus is characterised by high-amplitude contractions and should be di ff erentiated from contractility disorder secondary to outflow obstruction. Patients may present with dysphagia or pain. There is no well-proven treatment strategy for hypercon - tractile motility disorders. Patients should avoid any identifi - able triggering factors (e.g. dietary or GORD related). Similar to achalasia, medical therapy such as calcium channel blockers, nitrates, 5 /uni2032 -phosphodiesterase inhibitors and pain modulators hav e been used with limited e ffi cacy . Botulinum toxin injection in the oesophageal body may be useful. Long-segment surgical myotomy has been attempted with good results. POEM with extended myotomy is also advocated as a minimally invasive approach to treat these disorders.

(a) (b) Figure 66.28 gus (a) Creation of a mucosal opening. (b) A tunnel is created between the (d) Myotomy is carried out End-stage achalasia. A grossly dilated sigmoidal-shaped oesopha- (a) . Transected oesophagus (b) .

Functional oesophageal disorders According to the Rome IV classification, functional oesoph ageal disorders include a variety of oesophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by mechanical obstruction (stricture, tumour, EOO), major motor disorders (achalasia, OGJOO, absent contractility , distal oesophageal spasm, jackhammer oesophagus) or GORD. The mechanisms responsible are unclear but are likely to be more related to visceral hypersensitivity and hypervigilance. The diagnosis is generally by exclusion. Physiological and psycho logical factors should be considered. Among all the oesophageal disorders defined under the Rome diagnostic criteria, functional heartburn and reflux hypersensitivity contribute to most diagnostic confusion with genuine GORD. Therefor e, patients have to be carefully assessed before antireflux surgery is o ff ered. Pharmacological agents such as PPIs, tricyclic antidepressants, SSRIs and other pain modulators can be part of the treatment strategy . Surgery has a very limited role in the treatment and usually results in a poor outcome.

Figure 66.29 Barium contrast study showing a corkscrew oesopha gus in a patient with diffuse oesophageal spasm.