Oesophageal Dysmotility

The oesophagus is a long muscular tube measuring 25cms, which connects the back of the throat to the stomach. Food is propelled through the oesophagus by a co-ordinated series of contractions of the oesophageal muscle. These are called peristalsis. The oesophagus has nerve input from two sets of nerves which emerge from the central nervous system.

These disorders are classically diagnosed by oesophageal manometry studies, which assess:

• The pressure in the lower oesophageal sphincter and the degree of relaxation of the oesophageal oesophageal sphincter
• The presence of peristalsis (a co-ordinated propulsion of food or fluid) in the oesophageal body and the characteristics of the contraction waves including high or low amplitude, duration, repetitive nature, and the presence of either non transmitted or partly transmitted waves

Most assessments concentrate on the distal (lower) two thirds of the oesophagus. Normal values on manometry studies have been calculated through the study of large healthy populations.

Other tests which can be useful in making the diagnosis include barium swallow and gastroscopy.

Abnormalities in the motility of the muscle of the oesophagus can lead to symptoms of chest pain and dysphagia (difficulty swallowing). The classification for most disorders of oesophageal motor function is imprecise. Achalasia has a defined and identifiable pathological series of changes associated with it but other motor disorders do not. Chest pain can be associated with any disease of motility of the oesophagus. Patients may initially present to a doctor with what is thought to be angina of cardiac origin.

In addition, a significant proportion of patients with gastro-oesophageal reflux disease may suffer with ‘atypical’ chest pain which presents as angina. It is well recognised that these patients often restrict their lifestyle believing they have heart disease. These patients often respond to proton pump inhibitor drugs which profoundly suppress production of acid in the stomach.

A problematic feature of patients with oesophageal dysmotility syndromes is that there is an inconsistent association between oesophageal symptoms (such as chest pain), degree of dysmotility and psychological symptoms. In a study of 113 patients with various types of oesophageal dysmotility disorders, those with achalasia and diffuse oesophageal spasm had normal psychometric profiles. In contrast, those with other dysmotility disorders had increased psychological abnormalities including depression. Interestingly, in the entire cohort of patients, the presence of chest pain was closely associated with the presence of psychometric abnormalities.

Treatment is highly dependent on the nature of the problem and may also need to be tailored to the individual patient as different people respond differently to the medicines. Surgery is only rarely recommended for most oesophageal motility disorders.