Advances in Management of Esophageal Motility Disorders

Peter J. Kahrilas; Albert J. Bredenoord; Dustin A. Carlson; John E. Pandolfino


Clin Gastroenterol Hepatol. 2018;16(11):1692-1700. 

In This Article

Abstract and Introduction


The widespread adoption of high-resolution manometry (HRM) has led to a restructuring in the classification of esophageal motility disorder classification summarized in the Chicago Classification, currently in version 3.0. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or even with preserved peristalsis. Furthermore, despite these advances in diagnostics, no single manometric pattern is perfectly sensitive or specific for idiopathic achalasia and complimentary assessments with provocative maneuvers during HRM or interrogating the esophagogastric junction with the functional luminal imaging probe during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. Using these tools, we have come to conceptualize esophageal motility disorders as characterized by obstructive physiology at the esophagogastric junction, smooth muscle esophagus, or both. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. Now and going forward, optimal management is to render treatment in a phenotype-specific manner: e.g. POEM calibrated to patient-specific physiology for spastic achalasia and spastic disorders of the smooth muscle esophagus, more conservative strategies (pneumatic dilation) for the disorders limited to the sphincter.


The new millennium brought much change to the world of esophageal motility: major changes in instrumentation, diagnostic algorithms, and therapeutics. Basically, if you have an old book, you can throw it away. High-resolution manometry (HRM) is now firmly ensconced in the clinical paradigm, with the Chicago Classification (CC) v3.0[1] being part of the daily dialogue. peroral endoscopic myotomy (POEM) has become the go-to intervention for both achalasia and distal esophageal spasm in many leading centers.[2] Functional luminal imaging probe (FLIP) measurements are being used to calibrate therapeutic interventions and to provide alternative diagnostic criteria in equivocal HRM cases.[3] Then there is the opiate epidemic, creating a new family of syndromes that we are only beginning to appreciate.[4] None of this existed a decade ago. It is from this landscape that we write this Perspective.

Contemplating the evolution of motility diagnostics, HRM has proven to be a truly disruptive technology, fostering a series of innovations and revelations. The most fundamental innovation was changing the presentation format of motility data from line tracings to pressure topography plots. Alternatively called isobaric contour plots or Clouse Plots,[5,6] pressure topography plots use a coordinate system of time on the x-axis, sensor position on the y-axis, and pressure values as spectral color within that grid. Apart from elegantly condensing an enormous dataset into a single image, key advantages of this format are that it makes sphincters, propagated or non-propagated contractions, luminal pressure gradients, and isobaric regions within the esophagus visually obvious and easily interrogated with software tools. Hence, in a way that was never achieved with conventional manometry, HRM revealed clinically important patterns of obstructive physiology both at the esophagogastric junction (EGJ) and along the esophageal lumen. Although understanding its full relevance is still a work in progress, the concept of obstructive physiology as a fundamental abnormality of esophageal motility disorders has already substantially morphed their clinical management.