Esophageal Motility Disturbances



Esophageal Motility Disturbances


Michael P. Federle, MD, FACR





Key Facts


Imaging



  • Primary: Achalasia, diffuse esophageal spasm, presbyesophagus


  • Secondary: Scleroderma, various causes of esophagitis


  • Achalasia: Idiopathic or neurogenic disorder



    • Markedly dilated esophagus; absent primary peristalsis


    • “Bird-beak” deformity in esophagogastric region


  • Diffuse esophageal spasm (DES)



    • Contractions are repetitive, esophageal lumen may show “corkscrew” or “rosary bead” pattern


    • Often with chest pain during contractions


  • Presbyesophagus or NEMD: Multiple aperistaltic (tertiary) contractions and ↓ primary peristalsis


  • Scleroderma



    • Patulous GE region and reflux → fusiform distal peptic stricture; ± hiatal hernia


    • Absence of peristalsis in lower 2/3 of esophagus


Top Differential Diagnoses



  • Reflux esophagitis



    • Esophagitis may impair peristalsis


  • Fundoplication complications (especially in elderly)


  • Esophageal (or gastric fundus) carcinoma


  • Postoperative state, esophagus



    • Vagotomy may impair peristasis


    • Esophagectomy with gastric conduit


Diagnostic Checklist



  • Correlate: Clinical, radiographic, and manometric findings


  • Patients with esophageal dysmotility often complain of food sticking in cervical esophagus


  • Intermittent cricopharyngeal spasm identified, but not primary dysfunction






(Left) Upright esophagram in a 28-year-old woman with achalasia shows marked dilation of the esophageal lumen, ending in a smoothly tapered “bird-beak” deformity image. (Right) Esophagram in the same patient shows absent primary peristalsis and only weak intermittent tertiary contractions, causing the undulating surface contour.






(Left) Spot film from an esophagram in an elderly man with diffuse esophageal spasm shows intermittent obliterative contractions, imparting a “corkscrew” appearance image to the esophagus. (Right) Esophagrams in an elderly woman with esophageal spasm show obliterative, deep contractions. Multiple barium-filled pulsion diverticula are evident image, especially after the barium bolus has passed. Pulsion diverticula are closely associated with esophageal dysmotility.



TERMINOLOGY


Definitions



  • Primary and secondary motility disorders of esophageal smooth muscle


IMAGING


General Features



  • Best diagnostic clue



    • Achalasia: “Bird-beak” deformity; dilated esophagus with smooth, tapered narrowing at GE junction


    • Scleroderma: Dilated atonic esophagus with distal stricture


  • Other general features



    • Classification of esophageal motility disorders



      • Primary: Achalasia, diffuse esophageal spasm, presbyesophagus


      • Secondary: Scleroderma, various causes of esophagitis


    • Achalasia: Idiopathic or neurogenic disorder



      • Absence of primary peristalsis


      • Simultaneous low-amplitude contractions



        • May have prominent tertiary contractions (“vigorous achalasia”)


      • Increased or normal resting lower esophageal sphincter (LES) pressures


      • Incomplete or absent LES relaxation on swallowing


      • Normal upper esophageal sphincter


    • Diffuse esophageal spasm (DES): Related to varying degrees of neurogenic damage



      • Simultaneous contractions and intermittent primary peristalsis


      • Repetitive or prolonged-duration contractions


      • High amplitude and frequent spontaneous contractions


      • Normal LES function with complete sphincter relaxation during swallowing


      • Intermittent disruption of primary peristalsis associated with focally obliterative simultaneous contractions


    • Presbyesophagus: Esophageal motility dysfunction associated with aging



      • Also called nonspecific esophageal motility disorder (NEMD)


      • Decreased frequency of normal peristalsis


      • Increased frequency of aperistaltic contractions


      • Less commonly, incomplete LES relaxation


    • Scleroderma: Multisystemic disorder of small vessels and connective tissue



      • Decreased or absent resting LES pressure


      • Absent peristalsis in lower 2/3 of esophagus


    • Other esophagitises: Reflux, infectious, caustic

Tags:
Jun 8, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Esophageal Motility Disturbances

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