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Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
Esophageal motility disorders
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Esophageal motility disorders

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  • 1. Esophageal Motility DisordersEsophageal Motility Disorders
  • 2. Anatomy of The EsophagusAnatomy of The Esophagus The esophagus is a hollow muscularThe esophagus is a hollow muscular organ, approximately 25cm in length thatorgan, approximately 25cm in length that extend from the pharynx to the stomachextend from the pharynx to the stomach
  • 3. Anatomy of The EsophagusAnatomy of The Esophagus Cervical Esophagus:Cervical Esophagus: Just lies to the left ofJust lies to the left of midline behind the larynx and the trachea. Themidline behind the larynx and the trachea. The entry to esophagus called upper esophagealentry to esophagus called upper esophageal sphincter (UES).sphincter (UES). Thoracic Esophagus:Thoracic Esophagus: The upper part passesThe upper part passes behind the carina & Lt. main stem bronchus. Thebehind the carina & Lt. main stem bronchus. The lower part passes behind the left atrium.lower part passes behind the left atrium.
  • 4. Abdominal Esophagus:Abdominal Esophagus: Is the smallestIs the smallest portion of the esophagus (2-4cm length). Itportion of the esophagus (2-4cm length). It has lower esophageal sphincter (LES)-has lower esophageal sphincter (LES)- non anatomical with normal restingnon anatomical with normal resting pressure 10-20mmHg.pressure 10-20mmHg.
  • 5. Anatomy of The EsophagusAnatomy of The Esophagus Normal esophagealNormal esophageal narrowingnarrowing:: • UES at the level of cricoid cartilage 14mmUES at the level of cricoid cartilage 14mm in diameter.in diameter. • Broncho-aortic constriction 17mm inBroncho-aortic constriction 17mm in diameter.diameter. • LES (19mm) as it travels the diaphragm &LES (19mm) as it travels the diaphragm & located 3-5cm at distal part of thelocated 3-5cm at distal part of the esophagus.esophagus.
  • 6. Clinical Importance of normal esophagealClinical Importance of normal esophageal narrowing:narrowing: •Potential for development of diverticulum'sPotential for development of diverticulum's (Zenker) in the neck.(Zenker) in the neck. •Potential for perforation duringPotential for perforation during esophagoscopyesophagoscopy
  • 7. Anatomy of The EsophagusAnatomy of The Esophagus The esophageal wall:The esophageal wall: • The proximal esophagus is predominantlyThe proximal esophagus is predominantly striated muscle.striated muscle. • The distal esophagus is predominantly smoothThe distal esophagus is predominantly smooth muscle.muscle. • The mid esophagus contained a gradedThe mid esophagus contained a graded transition of striated and smooth muscle.transition of striated and smooth muscle.
  • 8. Physiology of The EsophagusPhysiology of The Esophagus The function of the esophagus is toThe function of the esophagus is to transport the ingested material from thetransport the ingested material from the pharynx to the stomach by peristalticpharynx to the stomach by peristaltic waves.waves. Primary peristalsis:Primary peristalsis: Triggered by theTriggered by the swallowing center in the brain stem andswallowing center in the brain stem and the contraction wave travel at speedthe contraction wave travel at speed 2cm/s.2cm/s.
  • 9. Secondary peristalsis:Secondary peristalsis: Induced byInduced by esophageal distensionesophageal distension from retainedfrom retained bolus, refluxed material. Its role is to clearbolus, refluxed material. Its role is to clear the esophagus form retained bolus.the esophagus form retained bolus.
  • 10. Tertiary peristalsis:Tertiary peristalsis: Tertiary contractions are non-propulsive and uncoordinated and their non-peristaltic nature means they move the bolus up as well as down the oesophagus. They are seen as intermittent ripples along the wall of the oesophagus lasting only a few seconds, as multiple simultaneous contraction rings or as a segmented barium column producing a corkscrew appearance.
  • 11. Tertiary contractions of the oesophagus seen as a rippling of the oesophageal wall
  • 12. A series of indentations resembling a corkscrew (hence the description 'corkscrew oesophagus')
  • 13. Mechanism of swallowingMechanism of swallowing During the pharyngeal phase of swallowing, aDuring the pharyngeal phase of swallowing, a primary peristalsis is created, that relax the UESprimary peristalsis is created, that relax the UES and forces the food bolus through it. The UESand forces the food bolus through it. The UES remain constricted and has resting pressure ofremain constricted and has resting pressure of 20-60 mmHg. The peristaltic waves travel at the20-60 mmHg. The peristaltic waves travel at the speed 2cm/s and reach the stomach in 5-10speed 2cm/s and reach the stomach in 5-10 secondsecond
  • 14. Secondary peristalsis get initiated if the primarySecondary peristalsis get initiated if the primary peristalsis failed to get food to the stomach and theperistalsis failed to get food to the stomach and the esophagus became distended.esophagus became distended.
  • 15. Esophageal Motility DisordersEsophageal Motility Disorders AchalasiaAchalasia Spastic esophageal motility disordersSpastic esophageal motility disorders such assuch as  diffuse esophageal spasmdiffuse esophageal spasm  nutcracker esophagusnutcracker esophagus  hypertensive /hypertrophic LEShypertensive /hypertrophic LES  Non-specific esophageal motility disorderNon-specific esophageal motility disorder  presbyo esophaguspresbyo esophagus
  • 16. Secondary esophageal motility disordersSecondary esophageal motility disorders related to , diabetes, alcoholrelated to , diabetes, alcohol consumption,collagen,endocrine andconsumption,collagen,endocrine and neuromuscular diseases.neuromuscular diseases.
  • 17. Esophageal Motility DisordersEsophageal Motility Disorders Achalasia (failure to relax)Achalasia (failure to relax) • Is the only esophageal motility disorder with anIs the only esophageal motility disorder with an established pathology.established pathology. • The predominant pathophysiology of achalasiaThe predominant pathophysiology of achalasia is theis the loss of Auerbachloss of Auerbach ganglion cells from theganglion cells from the wall of the esophagus ,starting at LES andwall of the esophagus ,starting at LES and progress proximally.progress proximally. • Incidence is 1-3 / 100,000 population / year.Incidence is 1-3 / 100,000 population / year.
  • 18. Esophageal Motility DisordersEsophageal Motility Disorders Achalasia (failure to relax)Achalasia (failure to relax) • Characterized by failure of LES to relaxCharacterized by failure of LES to relax completely during swallowingcompletely during swallowing Primary and secondary peristalsis initially fails, tertiary contractions develops ,leading to stasiss ,leading to stasis of food and subsequent dilatation.of food and subsequent dilatation. • Manometry may reveal elevated LES pressure >Manometry may reveal elevated LES pressure > 40 mmHg in 60% of patients.40 mmHg in 60% of patients.
  • 19. A barium swallow will show the gastro- oesophageal junction failing to open fully and tapering to a rat tail or bird beak appearance. Intact mucosal folds can be traced through this narrowed segment which at times opens briefly to allow a little barium to spurt into the stomach.
  • 20. Achalasia. The oesophagus is distended. Intact oesophageal folds pass through the tapered narrowing, which corresponds to the site of the lower oesophageal sphincter
  • 21. Esophageal Motility DisordersEsophageal Motility Disorders SPASTIC ESOPHAGEAL MOTILITY DISORDERSSPASTIC ESOPHAGEAL MOTILITY DISORDERS 1)Diffuse esophageal spasm (DES):1)Diffuse esophageal spasm (DES): This is probably related to fragmentalThis is probably related to fragmental degeneration of vagal nerve fibers.degeneration of vagal nerve fibers. • Characterized by simultaneous, repetitive highCharacterized by simultaneous, repetitive high pressure muscular contraction within thepressure muscular contraction within the esophagus.esophagus. • May be associated with severe intermittent chest pain, dysphagia and even food impaction.
  • 22. manometrically-verified diffusemanometrically-verified diffuse esophageal spasm revealsesophageal spasm reveals multiple, non-peristalticmultiple, non-peristaltic contractions that obliteratecontractions that obliterate much of the lumen.much of the lumen.
  • 23. 2)Nutcracker esophagus2)Nutcracker esophagus This is a manometric diagnosis in which patients with non-cardiac chest pain have primary peristaltic waves with pressures in excess of 180 mmHg (normally 100 mmHg). The barium swallow and oesophageal scintigram show normal peristalsis and cannot therefore be used to diagnose this condition.
  • 24. 3)Hypertensive /hypertrophic LES,Non-3)Hypertensive /hypertrophic LES,Non- specific.specific. This again is a manometric finding in which the resting lower oesophageal sphincter pressure is 40 mmHg or more
  • 25. 4)Non-specific esophageal motility disorder4)Non-specific esophageal motility disorder This term is used to describe the remaining abnormalities of motility, such as  incomplete lower oesophageal relaxation and  loss of peristalsis  solitary abnormal contractions
  • 26. 5) Presbyoesophagus5) Presbyoesophagus Abnormal motility in the elderly is referred to as presbyoesophagus,although an underlying cause, for example diabetes, can often be identified in such patients. Elderly patients with severely disordered motility may become symptomatic with chest pain or dysphagia.
  • 27. THE TRANSIT TESTTHE TRANSIT TEST Scintigraphic tests have been shown to be more sensitive than endoscopy radiography and manometry in the identification of patients with motility problems.
  • 28. Indications  patients with atypical chest pain (pain of cardiac type with normal ECG and enzymes)  patients with dysphagia but normal endoscopy/ barium studies  patients with suspected muscular or neuromuscular dysfunction
  • 29. The transit test demonstrates oesophageal function by visualising the passage of a swallowed bolus into the stomach. The labelled material may be prepared in either liquid or solid form – for example, orange juice labelled with 99mTc-DTPA, or scrambled egg labelled with 99m Tc colloid.
  • 30. Each swallow consists of one mouthful (8-10 ml) of the labeled material and is swallowed in a single gulp, the patient being asked not to swallow again for the next 30 s, during which time the image acquisition is made.(2-4 frames per second).
  • 31. The images can then be displayed as a cine loop, and time-activity curves derived for the upper third, middle third, lower third and whole oesophagus.
  • 32. A convenient way of displaying the entire study is to use a functional image, with distance on the vertical axis and time on the horizontal axis.
  • 33. Typically, three consecutive swallows may be obtained in the supine position, and a further three swallows in the sitting position. Between each swallow the oesophagus is rinsed with an unlabeled drink in order to clear residual activity
  • 34. The results can be expressed either qualitatively, or by using a grading system, or by measurement of the mean transit time between mouth and stomach.
  • 35. Transit through the upper third of the oesophagus usually takes about I s, through the middle third about 2 s, and through the lower third about 6 s, giving a transit time through the whole oesophagus of 8-10 s.
  • 36. Grading systems take into account the degree of delay in transit time, the severity of disruption of the transit pattern, and the frequency of the abnormality in repeated swallows. Qualitatively, several different patterns can be recognised:
  • 37. Normal. The bolus traverses the oesophagus in a single wave of peristalsis in 8-10 s or so, with no delay, no fragmentation of the bolus, and no reflux
  • 38. Condensed image of a normal swallow. Timescale (x axis) is 30 s, y axis corresponds to the length of the oesophagus with the mouth at the top and gastric fundus at the bottom. M = mouth; D = distance;S = stomach.
  • 39. Transfer dysphagia. Once initiated, transit shows a normal progression but there is delay in initiating swallowing, and sometimes fragmentation of the bolus in the pharynx
  • 40. Condensed image in a patient with pharyngeal incoordination leading to transfer dysphagia, showing fragmentation of the initial swallowed bolus but normal rate of transit through the rest of the oesophagus.
  • 41. Step-delay' pattern. The initial peristaltic wave dies out in the middle third of the oesophagus and the bolus then remains stationary until it is stripped down the lower third by the next peristaltic wave. Associated with reflux oesophagitis
  • 42. Condensed image from a patient with oesophagitis showing a 'step-delay' pattern with transient hold up of the bolus in the middle third of the oesophagus.
  • 43. Intraoesophageal reflux. The swallowed bolus proceeds normally to the lower third, then part or all of it refluxes back to the middle third, before being cleared by further peristalsis Associated with reflux oesophagitis
  • 44. Condensed image showing intraoesophageal reflux retrograde motion of part of the swallowed bolus from the lower end to the middle third, with later clearing by a second swallow. M = mouth;D = distance; S = stomach.
  • 45. Incoordinate. After swallowing, the bolus is immediately fragmented by dystonic contractions, and no peristaltic wave develops Patients with diffuse oesophageal spasm, frequent tertiary contractions, or presbyoesophagus typically show an incoordinate pattern with delayed transit
  • 46. Adynamic. Swallowing is initiated normally, but peristalsis is weak or absent and bolus remains in the middle third of the oesophagus if the patient is supine, or clears only very slowly from the lower oesophagus if the patient is sitting
  • 47. Patients with autonomic neuropathy associated with diabetes, and those with systemic sclerosis involving the oesophagus, typically show delayed clearance with adynamic patterns
  • 48. Condensed image in a patient with achalasia showing stasis of the swallowed bolus in the middle third of the oesophagus, with to-and fro movement caused by respiratory excursion.
  • 49. Esophageal Motility DisordersEsophageal Motility Disorders Scleroderma esophagusScleroderma esophagus Collagen vascular disease.Collagen vascular disease. Vasculitis damages the smooth muscle coat of the bowel and mainly involve the distal 2/3 ofand mainly involve the distal 2/3 of esophagus.esophagus. Muscle damage results in a loss of primary and secondary motility , development of tertiary contractions and weakening of LES causingand weakening of LES causing GERD.GERD.
  • 50. Scleroderma: Incompetence of the gastro-oesophageal sphincter resulting in severe reflux oesophagitis with structuring, oedematous mucosa (mosaic pattern) and deep ulceration.
  • 51. Esophageal Motility DisordersEsophageal Motility Disorders Clinical HistoryClinical History  Achalasia:Achalasia: • The hall mark is dysphagia to both solid andThe hall mark is dysphagia to both solid and liquid.liquid. • Regurgitation commonly occur at nightRegurgitation commonly occur at night • Retrosternal chest pain.Retrosternal chest pain. • Heartburn occur in 30% of patients which mayHeartburn occur in 30% of patients which may be related to food fermentation and lactic acid.be related to food fermentation and lactic acid.
  • 52. Esophageal Motility DisordersEsophageal Motility Disorders Clinical HistoryClinical History  Spastic motility disordersSpastic motility disorders • Chest pain is the hall mark which may mimicChest pain is the hall mark which may mimic angina due to esophageal distension.angina due to esophageal distension. • Dysphagia to both solid and liquid.Dysphagia to both solid and liquid.  SclerodermaScleroderma • Involve the esophagus in 80% of patients.Involve the esophagus in 80% of patients. • Symptoms are related to GERD [dysphagia,Symptoms are related to GERD [dysphagia, heartburn and regurgitation].heartburn and regurgitation].
  • 53. Esophageal Motility DisordersEsophageal Motility Disorders Problems to be consideredProblems to be considered  Coronary Artery Disease (CAD).Coronary Artery Disease (CAD).  Mechanical obstruction (tumor).Mechanical obstruction (tumor).  Achalaisa and scleroderma increase risk ofAchalaisa and scleroderma increase risk of esophageal cancer.esophageal cancer.
  • 54. Esophageal Motility DisordersEsophageal Motility Disorders DiagnosisDiagnosis  HistoryHistory  Physical examination-unremarkablePhysical examination-unremarkable  Barium SwallowBarium Swallow Bird peak appearance- classic forBird peak appearance- classic for achalasiaachalasia Rosary beads or corkscrew-Rosary beads or corkscrew- classic for DESclassic for DES
  • 55. Bird peak appearance- classicBird peak appearance- classic for achalasiaRosary beads orfor achalasiaRosary beads or corkscrew-classic for DEScorkscrew-classic for DES
  • 56. THANK YOUTHANK YOU

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