# Oesophageal Motility Disorders > Oesophageal motility disorders for MBBS Pathology: diffuse spasm corkscrew, nutcracker, scleroderma patulous sphincter and contrast with achalasia. - Canonical URL: https://prepelephant.com/topics/mbbs/pathology/oesophageal-motility-disorders-pathology - Exam / course: MBBS · Subject: Pathology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Oesophageal Motility Disorders", PrepElephant, https://prepelephant.com/topics/mbbs/pathology/oesophageal-motility-disorders-pathology ## Direct answer Beyond achalasia, the oesophageal motility disorders sort into three patterns examiners test: diffuse oesophageal spasm — intermittent, uncoordinated tertiary contractions giving chest pain and dysphagia with a corkscrew oesophagus on barium; nutcracker oesophagus — peristaltic but excessively high-amplitude contractions, the commonest manometric cause of non-cardiac chest pain; and the scleroderma oesophagus — smooth-muscle atrophy and fibrosis of the distal two-thirds with a patulous, non-functioning lower sphincter, giving the picture opposite to achalasia: free reflux with absent peristalsis. The diagnostic engine for all of them is high-resolution manometry with barium correlation, and the discrimination from achalasia — absent peristalsis with a sphincter that will not relax — is the comparison every viva asks. ## What you must remember - **Diffuse oesophageal spasm:** intermittent simultaneous contractions with chest pain and intermittent dysphagia, symptoms often triggered by cold or carbonated drinks; barium shows segmental contractions — the corkscrew or rosary-bead oesophagus; lower sphincter relaxes normally (unlike achalasia). - **Nutcracker oesophagus:** high-amplitude (typically over about 180 millimetres of mercury) distal peristaltic contractions — peristalsis preserved, sphincter normal; a leading manometric diagnosis in non-cardiac chest pain after coronary disease is excluded. - **Scleroderma (systemic sclerosis) oesophagus:** fibrosis and atrophy of smooth muscle in the distal two-thirds with incompetent lower sphincter — severe reflux, oesophagitis, strictures and Barrett metaplasia risk; the proximal striated-muscle third and upper sphincter are spared (as are skeletal-muscle syndromes elsewhere). - **Achalasia contrast (the exam axis):** absent peristalsis with incomplete lower sphincter relaxation and raised resting pressure — bird-beak; scleroderma gives absent peristalsis with an open, patulous sphincter — air-fluid level and reflux; spasm retains peristalsis between episodes. - **Ineffective oesophageal motility:** low-amplitude failed peristalsis seen with reflux disease and connective tissue disease — mild dysphagia, usually managed medically. - **Secondary causes to exclude before labelling primary:** Chagas disease (destroyed myenteric plexus — the great achalasia mimic), diabetes, amyloidosis and pseudoachalasia from gastric cardia malignancy infiltrating the plexus. - **Management in one line each:** spasm — calcium channel blockers or nitrates, botox or myotomy for refractory disease; nutcracker — pain modulation and reflux control; scleroderma — acid suppression, dilatation for stricture. ## Chest pain with a normal coronary angiogram A 45-year-old woman has been admitted twice with gripping retrosternal pain, each angiogram normal; she also describes intermittent food sticking, particularly with cold drinks. The barium swallow shows a ladder of segmental contractions — the corkscrew — and manometry confirms intermittent simultaneous contractions with normal lower sphincter relaxation: diffuse oesophageal spasm. Her treatment trial is medical first (a calcium channel blocker before meals, avoiding cold foods), with botulinum toxin or rarely myotomy reserved for refractory cases. The diagnostic discipline that earned the answer was excluding the two mimics: coronary disease first (done by the angiograms), then achalasia — excluded by the preserved intermittent peristalsis and normally relaxing sphincter. Her hospital's other teaching case is the 52-year-old woman with longstanding Raynaud phenomenon and tight fingers whose complaint is nightly heartburn and dysphagia that is worse for solids and liquids equally; barium shows a dilated, emptying oesophagus with an air-fluid level and free gastro-oesophageal reflux. Manometry shows aperistalsis of the distal oesophagus with a lower sphincter that rests open at near-zero pressure — scleroderma oesophagus, the mirror image of achalasia. The clinical consequences follow the physics: the sphincter that cannot close floods the defenceless mucosa with acid, so management is lifelong proton-pump inhibition, surveillance for the stricture-Barrett sequence, and dilatation when strictures form. Two chest-pain patients, two manometric fingerprints, and the general lesson: in oesophageal disease the pressure trace is the ECG. ## Where students slip The scleroderma-achalasia pair is reversed: both show absent distal peristalsis, so the discriminator — and the mark — is the sphincter, closed and hypertensive in achalasia, open and patulous in scleroderma; writing "bird-beak in scleroderma" is the classic error. Nutcracker and spasm are conflated; nutcracker contractions are peristaltic but too strong, spasm contractions are simultaneous — chest pain is common to both, the manometry is not. Finally, pseudoachalasia is forgotten: an older patient with rapidly progressive dysphagia and weight loss needs an endoscopy to exclude cardia carcinoma infiltrating the myenteric plexus before idiopathic achalasia is diagnosed — a safety point examiners deliberately probe. ## Frequently asked questions ### What barium appearance characterises diffuse oesophageal spasm? Segmental, uncoordinated contractions producing the corkscrew (or rosary-bead) oesophagus, with normal lower sphincter relaxation. ### How does nutcracker oesophagus differ from diffuse spasm manometrically? Nutcracker shows preserved peristalsis with excessively high-amplitude distal contractions; spasm shows simultaneous, uncoordinated contractions. ### How is the scleroderma oesophagus distinguished from achalasia? Both lack distal peristalsis, but the scleroderma lower sphincter is patulous with free reflux, whereas the achalasic sphincter fails to relax and rests hypertensive (bird-beak). ### Which infection destroys the myenteric plexus and mimics achalasia? Chagas disease, from Trypanosoma cruzi — the great secondary achalasia in South America. ### What is pseudoachalasia? Malignant infiltration of the lower oesophageal sphincter region, classically by gastric cardia carcinoma, reproducing the manometric and radiological picture of achalasia — endoscopy is mandatory in late-onset, rapidly progressing cases. ### Why does scleroderma cause severe reflux disease? Fibrous replacement of the distal smooth muscle disables both peristaltic clearance and lower sphincter competence, so acid contact time rises steeply, with stricture and Barrett risk.