Oesophageal Motility Disorders
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Direct answer
Oesophageal motility disorders are abnormalities of peristalsis or lower sphincter relaxation, identified by high-resolution manometry and classified using the Chicago classification. Diffuse oesophageal spasm shows premature or simultaneous contractions, nutcracker oesophagus shows high-amplitude contractions with normal relaxation, and achalasia shows incomplete relaxation with absent peristalsis. Chest pain and dysphagia are common presenting symptoms, and manometry separates these patterns far better than symptoms or barium studies alone.
What you must remember
- Achalasia: incomplete lower sphincter relaxation with absent peristalsis, subtyped in the Chicago classification into types I, II and III, with type II responding well to myotomy.
- Diffuse oesophageal spasm: premature or simultaneous contractions in at least about 20 per cent of wet swallows, with normal sphincter relaxation.
- Nutcracker oesophagus: high-amplitude distal peristaltic contractions with normal relaxation, causing chest pain, although books differ on how the Chicago classification now groups it.
- Ineffective motility: weak or failed peristalsis in most swallows, often coexisting with reflux and dysphagia.
- Barium features: a corkscrew oesophagus is the classic barium sign of diffuse spasm, while the bird-beak narrowing belongs to achalasia.
- Integrated relaxation pressure: a four-second measure of sphincter relaxation, raised in achalasia and in other outflow obstruction.
- Treatment for spasm: calcium channel blockers, nitrates and acid suppression give symptomatic relief, while peroral endoscopic myotomy is reserved for refractory cases.
Reading a manometry tracing step by step
A 45-year-old woman has night-time chest pain and dysphagia to both solids and liquids. A barium swallow shows a corkscrew pattern, and the team must decide between spasm and achalasia.
- Check sphincter relaxation: Integrated relaxation pressure shows whether the lower sphincter relaxes, and a raised value points to achalasia or outflow obstruction.
- Check peristalsis: Absent peristalsis suggests achalasia, whereas premature or simultaneous contractions suggest diffuse spasm.
- Measure contraction strength: Very high amplitude distal contractions point to a hypercontractile pattern, called nutcracker in older texts and jackhammer when extreme in newer Chicago versions.
- Count failed swallows: Weak or failed contractions in most swallows define ineffective oesophageal motility.
- Classify and correlate: The Chicago classification gives the final pattern, which is matched against the symptoms before treatment.
- Exclude a mimic: Malignancy at the gastro-oesophageal junction can mimic achalasia, so endoscopy comes before any treatment decision.
Where the exam tries to catch you
Motility questions usually hinge on one manometry feature and one barium sign.
- Trap: Calling every corkscrew barium pattern diffuse spasm without manometry. Correct: Barium suggests the pattern, but manometry confirms it and is the diagnostic test.
- Trap: Offering myotomy first for nutcracker oesophagus. Correct: Relaxation is normal in nutcracker, so symptomatic medical therapy comes first and myotomy is reserved for refractory cases.
- Trap: Prescribing nitrates as definitive therapy for achalasia. Correct: Nitrates and calcium channel blockers give only temporary relief, whereas myotomy or dilatation treats the outflow block.
- Trap: Ignoring reflux in ineffective motility. Correct: Weak peristalsis clears refluxate poorly, so acid suppression is part of the care plan.
Frequently asked questions
What is the manometric hallmark of diffuse oesophageal spasm?
Diffuse oesophageal spasm shows premature or simultaneous contractions in a substantial share of wet swallows, with normal lower sphincter relaxation. Barium swallow may show a corkscrew pattern, but manometry is needed to confirm the diagnosis.
How does nutcracker oesophagus differ from achalasia on manometry?
Nutcracker oesophagus shows high-amplitude peristaltic contractions with normal relaxation of the lower sphincter, whereas achalasia shows incomplete relaxation with absent peristalsis. The difference in sphincter relaxation is the key discriminating feature.
What is integrated relaxation pressure used for in oesophageal manometry?
Integrated relaxation pressure measures lower oesophageal sphincter relaxation averaged over a four-second window during swallowing. It is raised in achalasia and other outflow obstruction, and it is normal in diffuse spasm and nutcracker oesophagus.
Which drugs give symptomatic relief in diffuse oesophageal spasm?
Calcium channel blockers and nitrates are used for symptomatic relief in diffuse oesophageal spasm, with acid suppression for coexisting reflux. Their effect is often modest, so refractory patients may be considered for peroral endoscopic myotomy.