BY : Niloofar Azizi

1. Esophageal Motility Disorders BY : NiloofarAzizi

2. Esophageal Anatomy • The esophagus is a muscular tube that commences at the base of the pharynx at C6 and terminates in the abdomen, where it joins the cardia of the stomach at T11 .

3. cervical esophagus : begins as a midline structure that deviates slightly to the left of the trachea as it passes through the neck into the thoracic inlet. Thoracic Esophagus : At the level of the carina, it deviates to the right to accommodate the arch of the aorta. It then winds its way back under the left main-stem bronchus. Abdominal Esophagus : Immediately before entering the abdomen, the esophagus is pushed anteriorly by the descending thoracic aorta

4. Upper EsophagealSphincter (UES) Esophageal Body(cervical & thoracic) • 18 to 24 cm Lower EsophagealSphincter (LES)

5. Anatomic Narrowing • cricopharyngeus muscle (14 mm) • bronchoaortic constriction (15 – 17 mm) • diaphragmatic constriction (16 – 19 mm)

6. Normal Phases of Swallowing • Voluntary • oropharyngeal phase – bolus is voluntarily moved into the pharynx • Involuntary • UES relaxation • peristalsis • LES relaxation • Between swallows • UES prevents air entering the esophagus during inspiration and prevents esophagopharyngeal reflux • LES prevents gastroesophagealreflux

7. Motility Disorders • upper esophageal • UES disorders • neuromuscular disorders • esophageal body • achalasia • diffuse esophageal spasm • nutcracker esophagus • nonspecific esophageal dysmotility • LES • achalasia • hypertensive LES • primary disorders • achalasia • diffuse esophageal spasm • nutcracker esophagus • nonspecific esophageal dysmotility • secondary disorders • severe esophagitis • scleroderma • diabetes • Parkinson’s • stroke

8. Upper Esophageal Motility Disorders • cause oropharyngeal dysphagia (transfer dysphagia) • patients complain of difficulty swallowing • tracheal aspiration may cause symptoms • pharyngoesophageal neuromuscular disorders • stroke • Parkinson’s • poliomyelitis • ALS • multiple sclerosis • diabetes • myasthenia gravis • dermatomyositis and polymyositis • upper esophageal sphincter (cricopharyngeal) dysfunction

9. UES Disorders • cricopharyngeal hypertension • elevated UES resting tone • poorly understood (reflex due to acid reflux or distension) • cricopharyngeal achalasia • incomplete UES relaxation during swallow • may be related to Zenker’s diverticula in some patients

10. clinical manifestations • localizes as upper (cervical) dysphagia within seconds of swallowing • coughing • choking • immediate regurgitation or nasal regurgitation

11. diagnosis • swallow evaluation & modified barium swallow

12. Motility Disorders of the Body & LES • symptoms: usually dysphagia (intermittent and occurring with liquids & solids) • diagnostic tests • barium esophagram • endoscopy • esophageal manometry • disorders • achalasia • diffuse esophageal spasm (DES) • nutcracker esophagus • hypertensive LES • nonspecific esophageal dysmotility • hypomotility • hypermotlity

13. Achalasia • failure to relax which is said of any sphincter that remains in a constant state of tone with periods of relaxation Your own footer

14. 6per 100,000 population • is seen in young women and middle-aged men and women alike. epidemiology 1 pathology • is presumed to be idiopathic or infectious neurogenic degeneration , Severe emotional stress, trauma, drastic weight reduction, and Chagas' disease (parasitic infection with Trypanosomacruzi) • destruction of the nerves to the LES • degeneration of the neuromuscular function of the body 2

15. clinical presentation • dysphagia • regurgitation • weight loss • heartburn • postprandial choking • nocturnal coughing

16. diagnosis • esophagram • motility study • hypertensive LES (> 35 mm Hg) • fail to relax • a pressure above baseline • simultaneous mirrored contractions with no evidence of progressive peristalsis • low-amplitude waveforms

17. treatment surgical Esophagomyotomy (Heller myotomy) Esophagectomy resection nonsurgical medications : sublingual nitroglycerin, nitrates, or calcium channel blockers, Injections of botulinum toxin endoscopic : Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon

18. Diffuse Esophageal Spasm • Hypermotilitydisorder of the esophagus • esophageal contractions are repetitive, simultaneous, and of high amplitude

19. epidemiology female > male 1 pathology 2 Muscular hypertrophy and degeneration of the branches of the vagus nerve in the esophagus

20. Symptoms and Diagnosis • chest pain • Dysphagia • Regurgitation • Esophagram • manometric studies : • simultaneous, multipeaked contractions of high amplitude (>120 mm Hg) or long duration (>2.5 sec) • erratic contractions occur after more than 10% of wet swallows

21. Treatment • Nonsurgical • Pharmacologic • endoscopic intervention • Surgical : long esophagomyotomy

22. Nutcracker Esophagus - a hypermotility disorder also known as supersqueezeesophagus - hypertensive peristalsis or high-amplitude peristaltic contractions

23. Symptoms and Diagnosis • chest pain • dysphagia • Odynophagia • subjective complaint of chest pain with simultaneous objective evidence of peristaltic esophageal contractions on manometric tracings

24. treatment • Medical: • Calcium channel blockers, nitrates, and antispasmodics • Bougie dilation • avoid caffeine, cold, and hot foods

25. Hypertensive LES • LES pressure is above normal, and relaxation will be incomplete but may not be consistently abnormal. The motility of the esophageal body may be hyperperistaltic or normal

26. Symptoms and Diagnosis • chest pain • dysphagia Manometry: elevated LES pressure (>26 mm Hg) and normal relaxation of the LES Esophagram: narrowing at the GEJ with delayed flow

27. treatment • Endoscopic: • hydrostatic balloon dilation • surgical intervention: • laparoscopic modified Heller esophagomyotomy • partial antireflux procedure (e.g., a Dor or Toupet fundoplication) • Botox injections Your Logo

28. Nonspecific Esophageal Dysmotility • abnormal motility pattern • fits in no other category • Several collagen vascular disorders are known to cause abnormalities of esophageal motility scleroderma, dermatomyositis, polymyositis, and lupus erythematosus

29. Symptoms and Diagnosis • chest pain • Dysphagia • tend to experience morereflux symptoms and regurgitation barium esophagram manometric studies: incomplete relaxation (residual >5 mm Hg) Contractions of the esophageal body patterns: non-transmitted, triple-peaked, retrograde, low-amplitude (<35 mm Hg) or prolonged duration (>6 sec).

30. Summery

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