MOTOR DISORDERS OF THE ESOPHAGUS



Definition and Pathogenesis. Motility disor­ders may arise from disease of smooth muscle (scleroderma) or of the intrinsic nervous system (achalasia, Chagas’ disease). In achalasia, degen­eration of the ganglion cells in Auerbach’s plexus leads to increased tone and impaired relaxation of the lower esophageal sphincter, which is often associated with decreased peristalsis. The etiol­ogy of other motility disorders, such as diffuse esophageal spasm, is uncertain.

Clinical Manifestations. The three most com­mon motility disorders are achalasia, sclero­derma, and diffuse esophageal spasm, each of which exhibits a unique pattern of symptoms .

Diagnosis. The clinical history is often char­acteristic, and a cine esophagogram (Fig. 38-1) combined with esophageal manometric studies (Table 38-3) will confirm the diagnosis in most cases.

Treatment and Prognosis. Achalasia often re­sponds to brisk dilation of the lower esophageal sphincter with a pneumatic bag, a procedure thought to rupture some of the sphincter muscle fibers. Surgical myotomy (Heller procedure) may be beneficial for those few who do not respond to pneumatic dilation. Therapy for scleroderma includes chronic treatment of GERD with H2 blockers or antacids . Patients with diffuse esophageal spasm may respond to ni­troglycerin, anticholinergic agents, or calcium-’ channel blocking drugs, although results are often disappointing. Occasionally, good long-term resuits have been obtained from a longitudinal my­otomy.