SeminarOesophageal motility disorders
Section snippets
Causes and pathological findings
Achalasia is the most recognised motor disorder of the oesophagus and the only primary motility disorder with an established pathology. The term means “failure to relax”, and describes the predominant feature of this disorder—a poorly relaxing lower oesophageal (cardiac) sphincter. The first case of achalasia was reported more than 300 years ago by Thomas Willis.4 The patient's cardiospasm responded to dilation with a whalebone.
The cause of achalasia is unknown. Available data suggest that
Symptoms and cause
Diffuse oesophageal spasm is characterised by normal peristalsis intermittently interrupted by simultaneous contractions. The first description of oesophageal spasm is attributed to Osgood, who, in 1889, described six patients with severe chest pain and dysphagia with meals.26 When accurately defined manometrically, the disorder is quite rare, occurring in about 3–5% of patients assessed for oesophageal motility disorders.27
The cause of diffuse oesophageal spasm is uncertain. It is seen at any
Hypercontracting oesophagus
Patients with oesophageal-contraction pressures of high amplitude (two SD above the mean of a large group of normal individuals) are described as having a “nutcracker” oesophagus when the high pressure occurs in the oesophageal body,52 and a hypertensive lower oesophageal sphincter when resting lower-oesophagealsphincter pressures are raised.53 Apart from these contractions of increased pressure, all other contractions are peristaltic, although their duration can be longer than normal. These
Hypocontracting oesophagus
Most patients who are diagnosed as having non-specific oesophageal motility disorders have motility tracings characterised by either low-amplitude (<30 mm Hg) peristaltic or simultaneous contractions in the distal oesophagus, or failed peristalsis in which the wave does not traverse the entire length of the distal oesophagus.58 These abnormalities have been renamed “ineffective oesophageal motility”.58 The concept of low-amplitude waves being ineffective is supported by previous studies that
Secondary oesophageal motility abnormalities
Patients with secondary disorders of oesophageal motility have abnormal motility patterns secondary to a multisystem disease. In scleroderma, for example, motility abnormalities are found in about 80% of patients.62 The underlying disease process is caused by vascular obliteration and secondary fibrosis that affects the oesophageal smooth muscle and its innervation.63 This process produces a low pressure in the lower oesophageal sphincter (<10 mm Hg) and weak ineffective distal motility; the
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