Esophageal dysmotility is a disorder affecting the transport of food and liquids from the throat to the stomach. It occurs when the coordinated, wave-like muscle contractions of the esophagus (peristalsis) become impaired, uncoordinated, or absent. This muscular dysfunction prevents swallowed material from moving smoothly, often leading to the sensation that something is stuck or that swallowing is difficult. The condition includes various specific disorders impacting the muscle function of the esophageal body and the valve-like ring of muscle at its lower end.
Recognizing the Signs
The most common complaint associated with esophageal dysmotility is dysphagia, or difficulty swallowing, which typically involves both solid foods and liquids. This pattern of trouble with both consistencies often signals a motility problem rather than a physical blockage, which usually causes difficulty only with solids first. The severity of dysphagia can range from a mild sensation of food slowing down to a complete inability to pass a swallowed bolus.
Another frequent symptom is non-cardiac chest pain, which can be intense and often mimics the sensation of a heart attack. This pain results from powerful, uncoordinated, or spastic muscle contractions within the esophagus, such as those seen in diffuse esophageal spasm. Because the pain originates near the heart, a thorough cardiac evaluation is always performed first to rule out life-threatening issues.
Regurgitation is also common, where undigested food or saliva flows back up into the throat or mouth without the forceful retching of vomiting. This occurs because food is not being properly cleared into the stomach, often due to a failure of the lower esophageal sphincter to relax. If this material enters the windpipe, it can lead to coughing, choking, or recurrent lung infections, such as aspiration pneumonia.
Heartburn or reflux symptoms may occur, sometimes resistant to standard acid-reducing medications. This happens if the dysmotility impairs the esophagus’s ability to clear acid that has refluxed from the stomach. Some individuals may also experience odynophagia (pain specifically upon swallowing) or feel a constant, non-painful lump sensation in the throat known as globus. Persistent symptoms can eventually lead to reduced food intake, resulting in weight loss and malnutrition over time.
Factors Contributing to Dysmotility
Esophageal dysmotility is classified as either a primary disorder, originating in the esophagus itself, or a secondary disorder, arising from a systemic condition.
Primary Disorders
Primary disorders include specific diagnoses such as Achalasia, where the lower esophageal sphincter fails to relax and the esophageal muscle stops contracting. Diffuse Esophageal Spasm is characterized by multiple, simultaneous, and uncoordinated contractions. A third primary type is Hypercontractile esophagus, sometimes called nutcracker or jackhammer esophagus, which is marked by excessively strong muscle contractions.
Secondary Disorders
Secondary dysmotility often involves systemic diseases that impact nerve or muscle function throughout the body, including the esophagus. Scleroderma, an autoimmune disorder, can cause the esophageal muscles to stiffen and lose their ability to contract, often leading to severe reflux.
Diabetes Mellitus is a frequent contributor, with studies showing dysmotility in over 60% of patients, often linked to diabetic neuropathy. This nerve damage leads to weakened swallows and a reduction in lower esophageal sphincter pressure.
Other systemic factors include neurological conditions, such as Parkinson’s disease or stroke, which interfere with nerve signals required for proper muscle coordination. Additionally, Chagas disease, caused by a parasite, can destroy nerve cells in the esophagus. Certain medications, notably long-term use of opioids, have also been shown to cause esophageal muscle dysfunction.
Diagnostic Procedures
A definitive diagnosis of esophageal dysmotility relies on specialized procedures that measure the mechanical function of the esophagus.
High-Resolution Manometry (HRM)
The gold standard test for assessing muscle coordination and pressure is High-Resolution Manometry (HRM). This procedure involves passing a thin, pressure-sensitive catheter through the nose into the esophagus to record the pressure generated by the muscles during multiple swallows of water. The data collected is analyzed using the standardized Chicago Classification framework. This scheme uses metrics like the Integrated Relaxation Pressure (IRP) of the lower sphincter and the Distal Contractile Integral (DCI) to categorize the specific type of dysmotility. Precise classification is paramount, as it directly guides the selection of the most effective treatment.
Barium Swallow
Another common test is the Barium Swallow, or esophagram, where the patient drinks a liquid containing barium while X-ray images are taken. This imaging study visually demonstrates the shape of the esophagus, the speed of food transit, and any abnormalities in muscle contractions. A corkscrew appearance can suggest a spastic disorder, while a dilated esophagus with a tapered end (a bird’s beak) is characteristic of advanced Achalasia.
Upper Endoscopy
An Upper Endoscopy is often performed early in the diagnostic process to visually inspect the lining of the esophagus and stomach. While this procedure cannot diagnose dysmotility itself, it is necessary to rule out other structural issues, such as inflammation, tumors, or strictures, that could cause similar swallowing symptoms. Biopsies may also be taken during the endoscopy to check for conditions like eosinophilic esophagitis.
Managing and Treating the Condition
Treatment for esophageal dysmotility is highly individualized and depends on the precise type and severity of the disorder identified by manometry. Initial management focuses on lifestyle and dietary modifications to ease food transit. Simple changes include eating smaller, more frequent meals, chewing food thoroughly, and remaining upright after eating to minimize reflux and aid gravity.
Medical Management
For hypercontractile disorders like diffuse spasm, medical treatments aim to relax the hyperactive esophageal muscles. This involves medications such as calcium channel blockers or nitrates, which work as smooth muscle relaxants. These drugs help reduce the painful, strong contractions that cause non-cardiac chest pain.
Interventional Procedures
When the lower esophageal sphincter is tight or fails to relax, as in Achalasia, more aggressive treatments are required to open the valve. Endoscopic procedures include balloon dilation, which mechanically stretches the sphincter muscle to improve food passage. Another option is the injection of Botulinum toxin (Botox) directly into the sphincter muscle to temporarily paralyze and relax it.
Surgical Options
For long-lasting relief in severe cases, particularly Achalasia, surgery may be the most effective intervention. A Heller myotomy is a surgical procedure that involves cutting the muscle fibers of the lower esophageal sphincter to permanently relieve the obstruction. A newer, less invasive endoscopic option is Peroral Endoscopic Myotomy (POEM), which achieves a similar result by cutting the muscle from within the esophagus.