Esophageal motility disorders

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Abstract
Achalasia is a motility disorder with incomplete relaxation of the lower esophageal sphincter. The diagnosis of achalasia can be delayed up to 27 months, and approximately half of the patients may be misdiagnosed. Secondary achalasia is most commonly caused by adenocarcinoma at the gastroesophageal junction. Patients with secondary achalasia have a shorter duration to presentation, lose more weight, and are older. Pneumatic dilatation should be the initial treatment for achalasia. The majority of dilatations can be safely carried out on outpatients. Surgical myotomies should be reserved for pneumatic dilatation failures. Ambulatory manometry may be useful in identifying symptomatic patients having normal standard manometry. Segmental tertiary activity with complete lumen obliteration on barium radiography is predictive of abnormal peristalsis. Diltiazem may improve esophageal spasm, but in a recent double-blind, randomized study, there was no difference compared with placebo. Patients with stable angina who become refractory to antianginal therapy may have a component of reflux and should be evaluated with 24-hour pH monitor, lntraesophageal balloon distention is a helpful provocative test. However, a standard catheter needs to be developed. Provocative testing with edrophonium may be accomplished with either 80 µg/kg body weight or 10-mg intravenous bolus dose.

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