Esophageal motilty disorders

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Esophageal motilty disorders

  1. 1. Esophageal motility disorders Dr / Hytham Nafady
  2. 2. Types of esophageal contractions Esophageal contractions Primary Secondary Tertiary Propulsive Propulsive Non propulsive
  3. 3. Esophageal motility disorders Primary Secondary Achalasia GERD Diffuse esophageal spasm Scleroderma Nutcracker esoaphagus Chagas disease Hypertensive LES Post-operative
  4. 4. Primary Esophageal motility disorders Hypo-motility disorders Achalasia Hyper-motility disorders Diffuse esophageal spasm Nutcracker esophagus Hypertensive LES
  5. 5. Esophageal manometry
  6. 6. Diffuse esophageal spasm Barium swallow • Corkscrew esophagus Videofluoroscopy • Peristalsis: • > 30% repetitive tertiary contractions. Esophageal manometery • LES: • Occasionally hypertensive, occasionally incomplete relaxation.
  7. 7. Nutcracker esophagus Barium swallow Videofluoroscopy Esophageal manometery • Normal. • Peristalsis: • Hyper-peristalsis of distal esophagus. • LES: • Usually normal but occasionally hypertensive.
  8. 8. Hypertensive LES Barium swallow Videofluoroscopy Esophageal manometery • Normal. • Peristalsis: • Normal. • LES: • Resting pressure > 45 mm Hg
  9. 9. Presby esophagus • • • • • Abnormal esophageal motility in the elderly. irrespective of the kind of motility disorder. This includes: Diffuse esophageal spasm. Dilated esophagus with poor peristalsis.
  10. 10. Esophageal motility disorders: Achalasia of the cardia: Diffuse esophageal spasm: Presby esophagus: Scleroderma: Atrophy of the smooth muscles with replacement by fibrous tissue. Reflux esophagitis: C.P: Barium swallow / vidofluroscopy: Dysphagia. Regurgitation. Dysphagia. Odenophagia. Dilated esophagus with smooth tapering of its lower end giving bird beaks appearance. Absent primary peristalsis. Repitive (>30%) tertiary non propulsive contractions giving cork screw appearance. Asymptomatic esophageal Weak primary peristalsis. motility disorder in elderly. Tertiary contractions with cork screw esophagus. Dysphagia. Dilated atonic lower 2/3 of the esophagus (smooth Reflux. muscles). Normal motility of the upper 1/3 (striated muscles). Patulous lower esophageal sphincter with GERD. Dysphagia, Regurgitation, Heart burn. Granular mucosal pattern. Shallow ulcers in the distal esophagus. Esophagogastric pseudopolyp. Transverse fixed mucosal folds (step ladder pattern). Buckering & sacculations. Feline esophagus. Peptic stricture. Barret esophagus.
  11. 11. Postoperative secondary diffuse esophageal spasm • After laparscopic Nissen fundoplication.
  12. 12. Achalasia of the cardia
  13. 13. Definition • Esophageal motility disorder characterized by hypo-peristalsis & incomplete relaxation of the lower esophageal sphincter.
  14. 14. Etiology 1ry ACHALASIA •Degeneration of the Aeurbach’s plexus. 2ry ACHALASIA • Neoplastic. • Chagas disease. • Postoperative (laparoscopic Nissen fundoplication).
  15. 15. C.P 1RY ACHALASIA • Long standing dysphagia > 1 year. • Regurgitation. 2RY ACHALASIA • Short duration dysphagia < 6 month. • Odynophagia.
  16. 16. Demographics Age: • 1ry achalasia: young patients (30-50 y). • 2ry achalasia: older patients (> 60 y). Gender: • M=F.
  17. 17. Complications • Aspiration pneumonia. • Esophageal carcinoma.
  18. 18. Aspiration pneumonia
  19. 19. Chest PA • Mediastinal widening, with double contour of mediastinal borders (outer border represent dilated esophagus). • Mediastinal air fluid level. • Displacement of the azygo-esophageal recess. • Anterior bowing of the trachea. • Absent gastric air bubbles. Barium swallow • Dilated esophagus • Early  mild. • Later  marked (sigmoid shaped). • Bird beak deformity (smooth tapering of the distal end of the esophagus). Videofluoroscopy Esophageal manometery • Peristalsis: • Absent primary peristalsis. • LES: • incomplete relaxation.
  20. 20. Azygoesophageal recess
  21. 21. Azygoesophageal recess
  22. 22. Displacement of the azygoesophageal recess
  23. 23. Dilated esophagus with bird beak deformity
  24. 24. DD • 2ry achalasia (e.g esophageal carcinoma or Nissen fundoplication). • Scleroderma. • Reflux esophagitis, with stricture.
  25. 25. Primary achalasia Markedly dilated esophagus (> 4 cm in its maximum diameter). Short narrow segment (< 3.5 cm) Secondary achalasia (pseudoachalasia) Mildly dilated esophagus (less than 4 cm in its maximum diameter). Long narrow segment (> 3.5 cm) Eccentric narrowing Asymmetrical shouldering Mucosal nodularity.
  26. 26. 2ry achalasia after Nissen fundoplication Clips Barrot beak appearance
  27. 27. Achalasia Scleroderma Aperistaltic dilated esophagus. Narrowed esophago-gastric junction. Patulous esophago-gastric junction.
  28. 28. Achalasia Reflux esophagitis with stricture. Smooth tapering of the distal esophageal segment. Associated with aperistalsis. Associated with hiatus hernia. Gross dilatation of the esophagus. Rarely associated with gross dilatation.

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