Achalasia and ineffective esophageal motility

Abstract

Achalasia and ineffective esophageal motility (IEM) represent the extreme ends of the spectrum of esophageal motility disorders. Achalasia is characterized by aperistalsis in the body of the esophagus and failure of LES relaxation. Patients present with dysphagia for solids and liquids, bland regurgitation, chest pain, and weight loss. The diagnosis is suggested by the barium esophagram and confirmed by manometry. The goal of therapy is to (1) relieve symptoms, (2) improve esophageal emptying by disrupting the poorly relaxing LES, and (3) prevent the development of megaesophagus. Surgical myotomy and pneumatic dilation are the most effective treatments for disrupting the LES gradient. Botulinum toxin and calcium channel blockers may be useful therapies in older patients or those with severe co-morbid illnesses. Ineffective esophageal peristalsis is characterized by the presence of distal esophageal contractions of very low amplitude (30 mmHg) and/or non-transmitted contractions. It is the most common motility disorder in GERD patients, probably due to impaired cholinergic stimulation along the esophageal body. The diagnosis is best made with esophageal manometry combined with impedance testing to confirm poor bolus transit. Once established, IEM is not improved by acid-suppressive medications, most prokinetic drugs, or anti-reflux surgery.