Esophageal Motility Disorders

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Esophageal Motility Disorders

• Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts CDS),
  FACS, FCCP
• Consultant Asst. Professor of Cardiothoracic
  Surgery
• King Abdulaziz University College of Medicine

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Anatomy of The Esophagus

• The esophagus is a hollow muscular organ,
  approximately 25cm in length that extend from the
  pharynx to the stomach
• The pharynx is a muscular tube, approximately
  12cm in length that serve as entry to the
  esophagus and respiratory tract.

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Anatomy of The Esophagus

• Cervical Esophagus Just lies to the left of
  midline behind the larynx and the trachea. The
  entry to esophagus called upper esophageal
  sphincter (UES).
• Thoracic Esophagus The upper part passes behind
  the carina Lt. main stem bronchus. The lower
  part passes behind the left atrium.
• Abdominal Esophagus Is the smallest portion of
  the esophagus (2-4cm length). It has lower
  esophageal sphincter (LES)- non anatomical
• with normal resting pressure 10-20mmHg.

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Anatomy of The Esophagus

• Normal esophageal narrowing
• UES at the level of cricoid cartilage 14mm in
  diameter.
• Broncho-aortic constriction 17mm in diameter.
• LES (19mm) as it travels the diaphragm located
  3-5cm at distal part of the esophagus.
• Clinical Importance of normal esoph. narrowing
• Potential for development of diverticulum's
  (Zenker) in the neck.
• Potential for perforation during esophagoscopy
• Pills-induced stricture.

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Anatomy of The Esophagus

• The esophageal wall
• The proximal esophagus is predominantly striated
  muscle.
• The distal esophagus is predominantly smooth
  muscle.
• The mid esophagus contained a graded transition
  of striated and smooth muscle.

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Anatomy of The Esophagus

• The esophageal wall
• The muscle oriented in two perpendicular opposing
  layers an inner circular layer and outer
  longitudinal layers both called muscularis
  propria.
• The outermost layer of the esophagus called
  adventitia (fibro-areolar layer), but no serosa.
  This may contribute for cancer spread.
• Underneath the adventitia there is a longitudinal
  muscle layer and beneath there is circular layer.
• Between the two muscle layers there are network
  of sympathetic and parasympathetic fibers
  (myentric plexus)

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Anatomy of The Esophagus

• The esophageal wall
• Beneath the muscle layers lies the submucosa
  which contain mucus gland, blood and lymphatic
  vessels and network works of nerve fibers
  (meissners).
• Beneath the submucosa is the mucosa which consist
  of squamous epithelium except the distal 2cm at
  G-E junction (Z-line) or transition to columnar
  epithelium.

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Anatomy of The Esophagus

• Blood supply venous drainage
• Cervical esophagus received its arterial blood
  from inferior thyroid artery.
• Thoracic esophagus received its arterial blood
  from bronchial, aorta, left gastric artery and
  from inferior phrenic artery.
• The esophageal veins drain to periesophageal
  venous network to inferior thyroid vein in the
  neck and to azygos and hemiazygos veins in the
  thorax.

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Anatomy of The Esophagus

• Lymphatic drainage
• The lymphatic plexus are located in the mucosa
  and the muscular layers drained to mediastinal
  lymph nodes.
• Clinical facts about the esophagus
• Cervical esophagus is 5 cm in length and 15cm
  distance from upper incisors
• Thoracic esophagus is 12cm in length and 25cm
  distance from upper incisors
• Lower esophagus is 2cm in length 38cm from
  upper incisors

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Physiology of The Esophagus

• The function of the esophagus is to transport the
  ingested material from the pharynx to the stomach
  by peristaltic waves.
• Primary peristalsis Triggered by the swallowing
  center in the brain stem and the contraction wave
  travel at speed 2cm/s.
• Secondary peristalsis Induced by esophageal
  distension from retained bolus, refluxed
  material. Its role is to clear the esophagus form
  retained bolus.

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Physiology of The Esophagus

• Tertiary peristalsis Are non peristaltic
  contraction and play no known physiological role.
  Frequently observed in elderly people called
  (presbyesophagus), also seen in motility
  disorders.

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Physiology of The Esophagus

• Mechanism of swallowing
• During the pharyngeal phase of swallowing, a
  primary peristalsis is created, that relax the
  UES and forces the food bolus through it. The UES
  remain constricted and has resting pressure of
  20-60 mmHg. The peristaltic waves travel at the
  speed 2cm/s and reach the stomach in 5-10 second

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Physiology of The Esophagus

• Secondary peristalsis get initiated if the
  primary peristalsis failed to get food to the
  stomach and the esophagus became distended.

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Esophageal Motility Disorders

• Achalasia
• Spastic esophageal motility disorders such as
  diffuse esophageal spasm, nutcracker esophagus
  and hypertensive LES
• Secondary esophageal motility disorders related
  to scleroderma, diabetes, alcohol consumption ..

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Esophageal Motility Disorders

• Achalasia (failure to relax)
• Is the only esophageal motility disorder with an
  established pathology.
• The predominant pathophysiology of achalasia is
  the loss of Auerbach ganglion cells from the wall
  of the esophagus ,starting at LES and progress
  proximally.
• Incidence is 1-3 / 100,000 population / year.

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Esophageal Motility Disorders

• Achalasia (failure to relax)
• Characterized by failure of LES to relax
  completely during swallowing
• The loss of nerve ganglion along the esophageal
  wall cause a peristalsis leading to stasis of
  food and subsequent dilatation.
• Manometry may reveal elevated LES pressure gt 40
  mmHg in 60 of patients.

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Esophageal Motility Disorders

• Spastic esophageal motility disorders
• Diffuse esoph.spasm (DES) This is probably
  related to fragmental degeneration of vagal nerve
  fibers.
• Characterized by simultaneous, repetitive high
  pressure muscular contraction within the
  esophagus.
• The muscular wall is thickened, hypertrophied and
  is hypersensitive to stretching.

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Esophageal Motility Disorders

• Scleroderma esophagus
• Collagen vascular disease.
• Characterized by smooth muscle hypertrophy and
  mainly involve the distal 2/3 of esophagus
  gradually lead to loss of peristalsis and
  weakening of LES causing GERD.
• Involve the esophagus in 80 of patient with
  scleroderma.

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Esophageal Motility Disorders

• Clinical History
• Achalasia
• The hall mark is dysphagia to both solid and
  liquid.
• Regurgitation commonly occur at night
• Retrosternal chest pain.
• Heartburn occur in 30 of patients which may be
  related to food fermentation and lactic acid.

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Esophageal Motility Disorders

• Clinical History
• Spastic motility disorders
• Chest pain is the hall mark which may mimic
  angina due to esophageal distension.
• Dysphagia to both solid and liquid.
• Scleroderma
• Involve the esophagus in 80 of patients.
• Symptoms are related to GERD dysphagia,
  heartburn and regurgitation.

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Esophageal Motility Disorders

• Problems to be considered
• Coronary Artery Disease (CAD).
• Mechanical obstruction (tumor).
• Achalaisa and scleroderma increase risk of
  esophageal cancer.

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Esophageal Motility Disorders

• Diagnosis
• History
• Physical examination-unremarkable
• Barium Swallow
• Bird peak appearance- classic for
  achalasia
• Rosary beads or corkscrew- classic for DES

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Esophageal Motility Disorders

• Diagnosis
• Esophagoscopy to rule out tumor or inflammatory
  lesion but not to diagnose esophageal
  dysmotility.
• Manometry study is to evaluate the esophageal
  motor pattern, contraction amplitude and LES
  pressure.

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Flexible Gastro-Esophagoscope
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Esophageal Manometry Cath.
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Esophageal Manometry
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Esophageal Manometry
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Achalasia
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Esophageal Motility Disorders

• Treatment
• The primary goal is symptomatic relief directed
  at relieving the physiologic obstruction at the
  level of LES by surgical or balloon dilatation.
• Nitrate and Ca channel B blockers are
  currently used in all patients with esophageal
  motility disorders.
• Antireflux therapy e.g proton pump inhibitors
  (esomeprazol) prokinetic such as motilium or
  erythromycin.

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Esophageal Motility Disorders

• Treatment
• Botulinum toxin injection (Botox) Injected
  edoscopically in 4 quadrants into LES in treating
  patient with achalasia.
• Botox is a potential inhibitor of acetylcholine
  release from nerve terminals. It is indicated in
  those pt. not candidate for surgery or refuse
  surgery.
• Endoscopic balloon dilatation This is the
  standard therapy for patients with achalasia.
• The mechanism based on disruption of circular
  muscle.
• Balloon dilatation response rate is 70

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Esophageal Motility Disorders

• Treatment
• Surgery (Heller Myotomy) surgical treatment
  targets to disrupt the LES.
• This can be performed thoracoscopic or
  laparascopic.
• Outcome is excellent 80-100 response rate.

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Normal Esophagus
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Barrett Esophagus
Definition Intestinal metaplasia
Risk factors Age Male GERD Smoking
Treatment Antireflux therapy Medical Pump
inhibitors (esomeprazole) Prokinetic meds
(Motilium) Annual Surveillance
(esophagoscopy) Surgical Fundoplication
Annual Surveillance Complications
Dysplasia Adenocarcinoma lt1/Yr