Elsevier

The Lancet

Volume 358, Issue 9284, 8 September 2001, Pages 823-828
The Lancet

Seminar
Oesophageal motility disorders

https://doi.org/10.1016/S0140-6736(01)05973-6Get rights and content

Summary

Oesophageal motility disorders comprise various abnormal manometric patterns which usually present with dysphagia or chest pain. Some, such as achalasia, are diseases with a well defined pathology, characteristic manometric features, and good response to treatments directed at the pathophysiological abnormalities. Other disorders, such as diffuse oesophageal spasm and hypercontracting oesophagus, have no well defined pathology and could represent a range of motility changes associated with subtle neuropathic changes, gastro-oesophageal reflux, and anxiety states. Although manometric patterns have been defined for these disorders, the relation with symptoms is poorly defined and the response to medical or surgical therapy unpredictable. Hypocontracting oesophagus is generally caused by weak musculature commonly associated with gastro-oesophageal reflux disease. Secondary oesophageal motility disorders can be caused by collagen vascular diseases, diabetes, Chagas' disease, amyloidosis, alcoholism, myxo-oedema, multiple sclerosis, idiopathic pseudo-obstruction, or the ageing process.

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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