Internal Medicine

P1: OXT/OZN/JDO P2: PSB

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

558 Esophageal Motor Disorders

➣Typically, the mucosa appears normal, but stasis inflammation

or secondary Candidiasis may occur

➣The gastroesophageal junction usually can be crossed easily with

gentle pressure on the endoscope

■CT scan

➣May suggest malignancy if there is marked and asymmetric

esophageal wall thickening

differential diagnosis

■Severe GERD complicating scleroderma may simulate achalasia but

in such cases the LES is hypotensive and relaxes normally

■Cancer with secondary achalasia is usually associated with rapid and

severe weight loss

■Myocardial ischemia, GERD, dissecting aortic aneurysm may cause

chest pain similar to the esophageal motor disorders

management

What to Do First

■Define the diagnosis and exclude malignancy as an underlying cause

General Measures

■Evaluate the risk for aspiration and prevent it

specific therapy

Indications for treatment

■All symptomatic patients with dysphagia, regurgitation or chest pain

require therapy.

Treatment Options

■Calcium channel blockers: relieve chest pain and dysphagia

■Two tricyclic antidepressants, trazodone and imipramine also effec-

tive in relieving chest pain; sublingual or oral nitrates, and anti-

cholinergics may also be used

■Hot water improves esophageal clearance and decreases the ampli-

tude and duration of esophageal body contractions.

■In severe cases, pneumatic dilatation, or an extended myotomy

should be considered.

■Pharmacologic therapy is usually ineffective in achalasia and

endoscopic or surgical therapy is needed; endoscopically-applied

botulinum injection is safe and effective but the results rarely last

longer than 18 months