Oesophageal dysmotility refers to the pathological disruption of the normal sequential and coordinated muscle motion of the oesophagus to transport food from the oropharynx to the stomach 4. It is an umbrella term used to refer to the common pathophysiological endpoint of dysmotility that can be caused by various disorders, which subsequently have a common mode of presentation.
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Epidemiology
The incidence of motility disorders involving the oesophagus is poorly defined. Achalasia (an uncommon cause of oesophageal dysmotility) is said to have an approximate incidence of 1-3 per 100,000 in the USA 1.
Clinical presentation
Dysphagia and chest discomfort are common modes of presentation. Characteristically the dysphagia seen in motility disorders tends to involve both solids and liquids at the outset. Retrospective studies have reported dysphagia lasting up to six years at presentation. Associated dyspepsia, globus, and weight loss may also be present.
Depending on the underlying cause, certain features can be more prominent than others, for example:
- progressive solid and liquid dysphagia with chest pain as an early feature
- chest pain or dyspepsia as the prominent symptom, which may be unrelated to dysphagia
- features of severe acid reflux including dyspepsia, regurgitation, and dysphagia
Pathology
Most primary oesophageal dysmotility disorders tend to be idiopathic, though various infectious, genetic, and autoimmune mechanisms have been proposed. The exception to this is achalasia, which has a defined pathophysiology.
Secondary causes essentially relate to the involvement of the oesophagus in systemic disease such as scleroderma or as a consequence of significant gastro-oesophageal reflux disease.
Radiographic features
Plain radiograph
Patients with oesophageal dysmotility can be referred for chest x-rays when the dominant feature is chest pain or if there is a cough related to co-existing gastro-oesophageal reflux.
Chest radiographs can have non-specific findings but may show a dilated oesophagus with a sigmoid appearance in achalasia. A hiatus hernia may be noted.
Fluoroscopy
Contrast swallow examinations are commonly used to assess the oesophagus since they provide both anatomical and functional information. This is at times correlated with endoscopic and manometry findings if possible intervention is being considered. If fluoroscopy is unremarkable but the patient remains symptomatic, these tests can be pursued for clarification.
Common findings depending on the cause include:
-
achalasia
- dilated intrathoracic oesophagus
- air-fluid level
- bird beak or rat's tail appearance with tapering of the distal oesophagus towards the lower oesophageal sphincter
-
diffuse oesophageal spasm
- corkscrew or rosary bead appearance
- possible pseudodiverticula
-
scleroderma
- slightly dilated oesophagus
- reduced or absent peristalsis
- free gastro-oesophageal reflux
-
gastro-oesophageal reflux
- free gastro-oesophageal reflux
- mucosal changes of erosive oesophagitis
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