Esophageal dysmotility is a condition where the muscles of the esophagus, the tube connecting the mouth to the stomach, fail to contract or coordinate properly. This muscular dysfunction prevents the effective movement of food and liquids down to the stomach, a process known as peristalsis. The resulting disruption often leads to symptoms like difficulty swallowing, chest pain, and the regurgitation of undigested food. This disorder represents a group of conditions, including hypercontractile disorders like diffuse esophageal spasm and hypotonic disorders like achalasia, where the lower esophageal sphincter fails to relax. Treatment strategies are determined by the specific type and severity of the motility issue.
Initial Management Through Lifestyle and Diet
Management of esophageal dysmotility often begins with adjustments to daily life and eating habits. These modifications reduce the burden on the esophagus and minimize symptoms before introducing medications or procedures. Patients should eat smaller, more frequent meals throughout the day instead of three large meals.
Eating should be slowed down, with thorough chewing to create a finer bolus that is easier for the esophagus to move. Avoiding specific trigger foods can significantly alleviate symptoms, as certain items relax the lower esophageal sphincter or irritate the esophageal lining. Common triggers include:
- High-fat foods
- Chocolate
- Caffeine
- Alcohol
- Peppermint
- Carbonated beverages
Positional changes are an important behavioral strategy to prevent the backflow of contents. Individuals should remain upright for at least two to three hours after eating or drinking to allow gravity to assist with esophageal clearance. Additionally, elevating the head of the bed by six to eight inches helps reduce nocturnal regurgitation and reflux symptoms.
Pharmacological Interventions
For many patients, especially those with spastic motility disorders, medications are used to relax the hyperactive smooth muscles of the esophagus. Smooth muscle relaxants decrease the pressure within the esophageal muscle wall. These include long-acting nitrates, such as isosorbide dinitrate, and calcium channel blockers, such as diltiazem or nifedipine.
These drugs work by inhibiting muscle contraction, which can reduce the intensity of non-propulsive spasms and chest pain associated with conditions like diffuse esophageal spasm. These medications are typically taken before meals to maximize their effect on swallowing muscles. A side effect of this muscle relaxation can be an increased risk of gastroesophageal reflux because the lower esophageal sphincter is also affected.
Proton pump inhibitors (PPIs) are often prescribed concurrently, especially if the patient experiences significant heartburn or acid reflux symptoms. PPIs do not address the underlying muscular incoordination of the dysmotility itself. Instead, they reduce the production of stomach acid, managing the painful and damaging effects of concurrent reflux on the esophageal tissue.
Endoscopic and Minimally Invasive Procedures
When lifestyle changes and medication do not provide sufficient relief, or for severe cases like achalasia, procedures targeting the lower esophageal sphincter (LES) are considered. Pneumatic dilation involves inserting a specialized balloon endoscopically into the LES and rapidly inflating it to tear the muscle fibers. This forceful stretching weakens the sphincter, allowing food to pass more easily into the stomach.
Another minimally invasive option is the injection of botulinum toxin (Botox) directly into the LES muscle via an endoscope. The toxin temporarily paralyzes the muscle, causing it to relax and relieve the obstruction. While this method is generally safe and effective, its effects are temporary, lasting approximately six to twelve months, and repeated injections are often necessary to maintain symptom control.
Peroral Endoscopic Myotomy (POEM)
POEM is an effective endoscopic treatment for achalasia and other spastic disorders. In the procedure, a flexible endoscope is passed through the mouth, and a tunnel is created beneath the esophageal lining to access the muscle layers. The surgeon then precisely cuts the muscle fibers of the LES and the lower esophagus from the inside, achieving a full myotomy without external incisions. POEM offers a less invasive alternative to traditional surgery with a high success rate, often exceeding 90% for achalasia.
Surgical Approaches
For patients who have failed to achieve long-term relief from endoscopic treatments, a surgical myotomy may be recommended. The Heller Myotomy is typically performed using minimally invasive laparoscopic techniques. During this operation, the surgeon precisely cuts the muscle fibers of the lower esophagus and the upper part of the stomach.
The goal of the Heller Myotomy is to relieve the obstruction at the junction between the esophagus and the stomach. Because cutting the LES muscle can compromise the natural barrier to stomach acid, the myotomy is often accompanied by a partial fundoplication. This secondary procedure involves wrapping a portion of the stomach around the lower esophagus to create a new valve mechanism, which helps prevent severe post-operative acid reflux.
Esophagectomy
In cases of advanced achalasia where the esophagus has become massively dilated, tortuous, and non-functional, an esophagectomy may be necessary. This complex operation involves the surgical removal of the diseased esophagus and the reconstruction of a new path for food to reach the stomach.