Internal Medicine

P1: OXT/OZN/JDO P2: PSB

0521779407-E-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10

Esophageal Motor Disorders 557

Signs & Symptoms

■Dysphagia and/or chest pain main symptoms

■Both symptoms intermittent, non-progressive and worse with cold

liquid ingestion

■Dysphagia noted with either solids or liquids

■Odynophagia suggests superinfection by Candida

■Heartburn, if present, raises the suspicion of secondary dysmotility,

due to GERD

■Regurgitation of undigested food is mostly a feature of achalasia and

it may lead to aspiration or weight loss

tests

Basic Tests

■Chest X-ray shows widening of the mediastinum in achalasia due to

the dilated esophagus, and absence of the normal gastric air bubble.

■Barium swallow may reveal tertiary contractions (described as

“rosary bead” or “corkscrew” esophagus); however, radiographic

studies may be entirely normal.

➣In achalasia, barium swallow shows a dilated, sigmoid-shaped

esophagus and in a beak-like narrowing caused by the poorly

relaxing, hypertensive LES

Specific Diagnostic Tests

■Esophageal motility study

➣Characteristic manometric features of achalasia: 1) Elevated rest-

ing LES pressure, usually above 45 mmHg; 2) Incomplete LES

relaxation; and 3) aperistalsis.

➣In cases of vigorous achalasia, the simultaneous esophageal con-

tractions have higher amplitudes.

➣Diffuse esophageal spasm: characterized by high amplitude

(>300 mmHg), simultaneous contractions

➣Nutcracker esophagus: distal esophageal peristaltic contractions

of >180 mmHg

➣Hypertensive lower esophageal sphincter: pressure >45 mmHg

➣Nonspecific dysmotility: frequent incoordinated contractions of

normal amplitude and duration

Other Tests

■Endoscopy

➣Recommended for all patients with achalasia to exclude malig-

nancy (pseudoachalasia)