Esophageal Motility Disorders

 

Am Fam Physician. 2020 Sep 1;102(5):291-296.

Author disclosure: No relevant financial affiliations.

Esophageal motility disorders can cause chest pain, heartburn, or dysphagia. They are diagnosed based on specific patterns seen on esophageal manometry, ranging from the complete absence of contractility in patients with achalasia to unusually forceful or disordered contractions in those with hypercontractile motility disorders. Achalasia has objective diagnostic criteria, and effective treatments are available. Timely diagnosis results in better outcomes. Recent research suggests that hypercontractile motility disorders may be overdiagnosed, leading to unnecessary and irreversible interventions. Many symptoms ascribed to these disorders are actually due to unrecognized functional esophageal disorders. Hypercontractile motility disorders and functional esophageal disorders are generally self-limited, and there is considerable overlap among their clinical features. Endoscopy is warranted in all patients with dysphagia, but testing to evaluate for less common conditions should be deferred until common conditions have been optimally managed. Opioid-induced esophageal dysmotility is increasingly prevalent and can mimic symptoms of other motility disorders or even early achalasia. Dysphagia of liquids in a patient with normal esophagogastroduodenoscopy findings may suggest achalasia, but high-resolution esophageal manometry is required to confirm the diagnosis. Surgery and advanced endoscopic therapies have proven benefit in achalasia. However, invasive interventions are rarely indicated for hypercontractile motility disorders, which are typically benign and usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.

Esophageal motility disorders are relatively uncommon conditions that are thought to cause chest pain or dysphagia in some patients. They are diagnosed not by specific symptoms or imaging studies, but on the basis of specific patterns seen on esophageal manometry, ranging from the complete absence of contractility in patients with achalasia to unusually forceful or disordered contractions in those with hypercontractile motility or “esophageal spasm” disorders.1

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should ensure optimal evaluation and management of common conditions such as gastroesophageal reflux disease and functional esophageal disorders before referring patients for testing for esophageal motility disorders.1,47

C

Consensus guideline and expert opinion

Patients with dysphagia should be asked about opioid use and helped to discontinue or taper the medication.7

C

Disease-oriented retrospective review

High-resolution manometry is required to confirm the diagnosis of achalasia.17

C

Clinical guideline

Esophageal motility disorders usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.6,25

B

Case series and longitudinal cohort study

Patients with achalasia should undergo definitive therapy when possible.28

C

Expert opinion and guideline

Invasive procedures are rarely needed for patients with hypercontractile motility disorders.2

B

Small randomized controlled trial


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should ensure optimal evaluation and management of common conditions such as gastroesophageal reflux disease and functional esophageal disorders before referring patients for testing for esophageal motility disorders.1,47

C

Consensus guideline and expert opinion

Patients with dysphagia should be asked about opioid use and helped to discontinue or taper the medication.7

C

Disease-oriented retrospective review

High-resolution manometry is required to confirm the diagnosis of achalasia.17

C

Clinical guideline

Esophageal motility disorders usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.6,25

B

Case series and longitudinal cohort study

Patients with achalasia should undergo definitive therapy when possible.28

C

Expert opinion and guideline

Invasive procedures are rarely needed for patients with hypercontractile motility disorders.2

B

Small randomized controlled trial


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Achalasia has well-defined and objective diagnostic criteria, as well as effective evidence-based treatment options, but its diagnosis is often

The Authors

show all author info

JOHN M. WILKINSON, MD, is a consultant in the Department of Family Medicine and an associate professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn....

MAGNUS HALLAND, MD, is a consultant in the Division of Gastroenterology and Hepatology and an assistant professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science.

Address correspondence to John M. Wilkinson, MD, Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 1st St. SW, Rochester, MN 55905 (email: wilkinson.john@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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