Spastic esophageal motility disorders
Each of the esophageal spastic motility disorders has certain manometric findings that are either diagnostic or associated. Note the following:
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DES is characterized by the findings of simultaneous contractions greater than 30% of water swallows, with the presence of normal peristalsis. [7] Other associated manometric findings may include repetitive contractions (>2 peaks), prolonged contractions (>6 s), high-amplitude contractions (>180 mm Hg), spontaneous contractions, incomplete LES relaxation, and increased LES pressure (>40 mm Hg).
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Nutcracker esophagus: These manometric abnormalities are the most common of the spastic motility disorders. The characteristic criterion is normal-patterned peristalsis with high-amplitude contractions greater than 180 mm Hg (2 standard deviations above the normal mean). The manometric findings associated with this condition may include repetitive contractions (>2 peaks), prolonged contractions (>6 s), and increased LES pressure (>40 mm Hg).
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Hypertensive LES: This is characterized by increased LES pressure of greater than 40 mm Hg that otherwise relaxes normally. Esophageal peristalsis is normal. Of note, elevated LES pressures may also be seen in patients with achalasia, nonspecific motility disorders, nutcracker esophagus, and DES; however, they are characterized by abnormal esophageal body motility. The significance of hypertensive LES is questionable.
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Nonspecific esophageal motor disorders: When peristaltic abnormalities are insufficient to establish one of the other motility disorders, the disorder is labeled as a nonspecific esophageal motor disorder (NEMD). Establishing a direct relation to symptoms is extremely difficult. This condition may include the following: nontransmitted waves (>20%), retrograde contractions, repetitive contractions (>2 peaks), low-amplitude contractions (< 30 mm Hg) or failed peristalsis (also referred to as inefficient esophageal motility [IEM]), isolated prolonged contractions (>6 s) or high-amplitude contractions (>180 mm Hg), spontaneous contractions, and incomplete LES relaxation. These nonspecific findings are not generally correlated to any symptoms. [8]
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The typical picture of achalasia. Note the "bird-beak" appearance of the lower esophageal sphincter (LES), with a dilated, barium-filled esophagus proximal to it. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison.
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The response to amyl nitrate (a smooth muscle relaxant), with partial relaxation of the lower esophageal sphincter (LES), allows some barium to pass through it into the stomach. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison.
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Esophagram of a 65-year-old man with rapid-onset dysphagia over 1 year. Although esophagram shows a typical picture of achalasia, this patient had adenocarcinoma of the gastroesophageal junction. This is an example of pseudoachalasia, which reinforces the absolute need for esophagogastroduodenoscopy (EGD) in patients with radiologic diagnosis of achalasia. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison.
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An esophagram demonstrating the corkscrew esophagus picture observed in a patient with manometry confirmed findings of diffuse esophageal spasm (DES). Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison.
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Response to amyl nitrate, with disappearance of the spasm on esophagram. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison.
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Normal manometry results show normal esophageal body peristalsis with normal lower esophageal sphincter (LES) pressure and relaxation. The LES pressure tracing is at the level of the sleeve (tracing 6).
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Achalasia manometry picture Note the nonrelaxing lower esophageal sphincter (LES) and the absence of esophageal body peristalsis. The LES pressure tracing is at the level of the sleeve (tracing 6).
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Manometry demonstrates diffuse esophageal spasm with simultaneous contractions of the esophagus observed throughout the tracing. The lower esophageal sphincter (LES) pressure tracing is at the level of the sleeve (tracing 6).
