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UNIVERSIDAD TECNICA DE MACHALA
ACADEMIC UNIT OF CHEMICAL
SCIENCES AND HEALTH
MEDICINE SCHOOL
ENGLISH
ESOPHAGEAL MOTOR
DISORDERS
STUDENTS
William Cruz
Kevin Herrera
TEACHER:
Mgs. Barreto Huilcapi Lina Maribel
CLASS:
EIGHTH SEMESTER ‘’A’’
Machala, El Oro
2018

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Esophageal Motor Disorders
Definition
Motor disorders of the esophagus are the result of the alteration of the peristaltic
activity of the esophageal body and / or operation of your sphincters. There are two
types of motor disorders of the esophagus: on the one hand there are those affect the
oropharynx and upper esophageal sphincter, which they are usually secondary to
other processes, and to we are not going to refer, and motor disorders that affect to
the esophageal body and / or lower esophageal sphincter (LES). These latter times
may be secondary, and accompany other processes, such as scleroderma, tissue
diseases connective and others, and we are not going to refer to them either, and
primary motor disorders of the esophagus, which are those in which the peristalsis of
the esophageal body is affected and / or pressure and / or functionalism of the lower
esophageal sphincter, whose alteration is not secondary to another disease and its
Clinical and functional manifestations are circumscribed exclusively to the
esophagus. Primary motor disorders of the esophagus (TMEP) are achalasia,
idiopathic diffuse esophageal spasm (EDEI), and those that can be included in the
group of hyper-contractile motor disorders, such as peristalsis esophageal esophagus
or esophagus in nutcracker (PES) and the hypertonic lower esophageal sphincter.
With some frequency
the so-called non-specific motor disorders are added and intermediate forms, that due
to the non-specific character which are called prefi ero not include them in the group
of primary esophageal motor disorders.

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Etiology
The spastic motor disorders of the esophagus are divided into primary and secondary.
Among the primary ones we found the EED, the esophagus in "nutcracker" or
nutcracker and the hypertensive EEI. The secondary ones are the most frequent;
mostly in relation to gastroesophageal reflux disease (GERD), although they can also
be due to other causes (neoplastic, systemic diseases, stenosing lesions, etc.)
The physiopathological mechanisms are unknown. Several studies have implicated
nitric oxide (NO) and its metabolism in the etiopathogenesis of these disorders. The
studies carried out point to an endogenous alteration in the synthesis and degradation
of this molecule in the esophagus, which causes dysfunction in normal peristalsis. It
has not been possible to document histopathological abnormalities, as in the case of
achalasia, except for a greater thickness of the muscularis propria in some cases.
Likewise, the involvement of excitatory neurotransmitters (cholinergic) in the
regulation of esophageal contractility has been observed.
Signs and symptoms
Regurgitation is also more frequent in typical achalasia and has a passive character,
unlike that which occurs in hypercontractile motor disorders, in which it is less
frequent, active and related to the intake. TMEP can present with chest pain, more
frequent in hypercontractile disorders than in achalasia. This pain is sometimes quite
similar to that of ischemic heart disease and in its study, when the similarity is such, it
is inexcusable, due to its important importance, to have reasonably ruled out said
heart disease before attributing it to a TMEP. Another symptom is weight loss, which
appears almost exclusively in typical and evolved achalasia. In the clinical context of
these patients, it is necessary to highlight the frequency that psycho-emotional factors
and stress sometimes have, to the point that Richter suggests that hyper-contractile
disorders can sometimes represent an epiphenomenon rather than a true TMEP.

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Once the clinical suspicion of TMEP is established, we have several complementary
explorations to confirm the diagnosis. The radiographic study with barium contrast,
which is normal in some cases, provides valuable information to establish the
diagnosis, especially in achalasia and EDEI, and it is of little use in hypertonic PES
and LES.
Diagnosis
This dysfunction of esophageal peristalsis usually manifests in the form of chest pain
and / or dysphagia. Therefore, before any patient with compatible symptoms, it is
important to rule out a heart disease before starting any treatment. Once the cardiac
origin has been ruled out, the esophageal study will be performed: upper
gastrointestinal endoscopy is usually normal in most cases and its greatest use is to
exclude other causes of dysphagia. Radiologic techniques can raise the suspicion of
spastic motor disorder if we find a typical image like the corkscrew esophagus.
Esophageal manometry is the indispensable method for the diagnosis of motor
disorders of the esophagus. The diagnosis of esophageal spasm is obtained after the
finding, in more than 20% of the swallows, of simultaneous contractions in the distal
esophagus (contraction forehead velocity greater than 8 cm / s), with an amplitude of
at least 30 mmHg and with a complete relaxation of the LES. The nutcracker
esophagus is characterized by a normal velocity of propagation (<8 cm / s in more
than 90% of swallows), together with hypertensive waves (amplitude> 180 mmHg).
In recent years, the appearance of high-resolution manometry has allowed us to better
characterize these disorders16. It consists of continuous monitoring of esophageal
intraluminal pressure with 36 pressure sensors separated by 1 cm between them.
Using this methodology, the recent Chicago classification divided the esophageal
motility disorders into two groups according to whether or not complete relaxation of
the LES was evidenced in response to swallowing during the manometric study. The
first group includes disorders with incomplete relaxation of the LES, among which
we find mainly achalasia and functional obstruction of the gastroesophageal junction.

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Treatment
Since the etiopathogenic bases of the disease are not exactly known, treatment is
often difficult. The coexistence of EED and GERD has been documented in some
cases, so one of the proposed treatments is with proton pump inhibitors.
Taking into account that hyperperistalsis is the characteristic alteration of this
disorder, drugs that inhibit muscular motor activity are the treatment of first choice,
mainly the calcium and nitrate antagonists (isosorbide mononitrate). With said
therapy, the amplitude of the contraction waves is reduced, although the symptoms
referred by the patients are not always improved. Among the calcium channel
antagonists, nifedipine has shown a relaxing action of the esophageal musculature
superior to diltiazem. The recommended dose is 10 mg administered three times a
day. Yet
being the most used, its use is limited by the high number of adverse effects. Nitrates
are the alternative to calcium antagonists. Its action is because they are donors of NO,
which acts as a powerful inhibitory neurotransmitter. Other types of drugs that may
be useful
in the treatment are inhibitors of phosphodiesterase (sildenafil) and other drugs such
as antidepressants or peppermint oil.
It has been pointed out that phosphodiesterase inhibitor drugs may be useful for their
ability to decrease the amplitude of contractions, since it increases the availability of
NO in the esophagus. Also, sildenafil and
Other inhibitors of type V phosphodiesterase enhance the endogenous action of NO
and reduce contractility in smooth muscle for several hours. The control of symptoms
it is obtained with doses of 25-50 mg of sildenafil daily13. In the cases described by
Fox et al, it was also possible to demonstrate the normalization of esophageal
manometry and the improvement of symptoms when this drug was administered.
Although it has less adverse effects than nitrates, its cost is very high, so its use has
not yet been generalized.

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Prevention
The best way to prevent this disease is to eliminate the risk factors, through general
measures or avoid exposure to triggers.
Bibliography
 Spechler SJ. American gastroenterological association medical position
statement on treatment of patients with dysphagia caused by benign disorders
of the distal esophagus. Gastroenterology 1999; 117: 229-232
 Varadarajulu S, Eloubeidi MA, Patel RS, Mulcahy HE, Barkun A, Jowell P et
al. The yield and the predictors of esophageal pathology when upper
endoscopy is used for the initial evaluation of dysphagia. Gastrointest Endosc
2005; 61: 804-808
 Gupta S, Levine MS, Rubesin SE, Katzka DA, Laufer I. Usefulness of barium
studies for differentiating benign and malignant strictures of the esophagus.
AJR Am J Roentgenol 2003; 180: 737-744.