Oesophageal Motility Disorders:

Ibrahim Sadic Mikhel El Bohy

The oesophagus is a muscular tube serves asa conduit for the passage of food from the pharynxto the stomach. Separating its lower end from thestomach is a zone of increased pressure that actsas a barrier to reflux of stomach contents butallows materials to pass in both directions.The act of swallowing is accomplished by thecoordinated movement of striated muscles and thestriated and smooth musculature of the tubularoesophagus, all under central control.Each individual has an unique swallowing patternand the increasingly widespread use of variousoesophageal function tests has clarified the natureof a variety of oesophageal motility disorders.As a result, most benign conditions of the oesophaguscan now be classified according to their specificabnormal motility pattern.The oesophageal motility disorders classifiedaccording to the system affected to; diseases affectthe upper oesophageal sphincter and those involvingthe body of the oesophagus and lower oesophagealsphincter...Upper oesophageal dysphagia may follow certainlessions of the central nervous system; musculardiseases due to impairment of pharyngeal contractionsand after extensive operations on the oropharynx,presumbly because of impaired function of the cricopharyngeusmuscle. ”Spasm” or hypertension of theupper oesophageal sphincter is another possiblecause of oropharyngeal dysphagia. The most commonentity responsible for upper oesophageal dysphagiais pharyngo-oesophageal diverticulum or Zenker’sdiverticulum. Cricopharyngeal myotomy has playedan increasing role in the management of abnormalitiesof function of the upper oesophageal sphincter.More is known about the abnormalities affectingthe body of the oesophagus and its lower sphincterthan about those of the upper sphincter, hence,this rather arbitary division in the classification.A further division into abnormalities of functioncharacterized by hypo-and-hypermotility is usefulfor it has clinical and therapeutic implication.Even so, many major gaps in our knowledge remainregarding the function of the body and the lowersphincter, as indicated by the number of conditionslisted under ”miscellaneous” which ·reflects thecomplixity of the response of this part of theoesophagus to a wide variety of conditions.Oesophageal achalasia is a disease of unknownorigin characterized by the absence of peristalsisin the body of the oesophagus, failure of or incom(plete relaxation of the lower oesophageal sphincterin response to swallowing and a. higher than normalresting lower oesophageal sphincter pressure. Surgicaltreatment provides a higher success rate andlong lasting relief of dysphagia than forcefuldilation.One of the most common abnormalities of oesophagealfunction is gastro-oesophageal reflux secondaryto hypotension of the lower oesophageal sphincter.Hypotensive lower oesophageal sphincter existsin a variety of conditions, probably the most Commonof which is sliding oesophageal hiatus hernia.The diagnosis of gastro-oesophageal reflux secondaryto hypotensive lower oesophageal sphincter is basedon clinical, roentogenographic, endoscopic andmanometric criteria. Objective evidence of gastrooesophagealreflux must be sought in such patientsbecause the symptoms may not always definitiveto confirm the diagnosis. Probably the most sensitivetest for reflux is the pH reflux test, with manometryand cinefluorography being less reliable indexes.Treatment is primarily medical and is designedto minimize the occasions of reflux and its effectsby reducing gastric acids. In a small percentageof patients, surgical treatment in the form ofaifantireflux poceduros required.Hypermotility disturbances of the oesophagus-137are less common than hypomotility disturbances.Most frequently encountered is diffuse spasm ofthe oesophagus, a functional abnormality that mayor may not be associated with elevated lower oesophagealsphincter pressures. Manometric studies usuallyidentify the abnormality as restricted to the lowertwo third of the oesophagus. The deglutitory peristalticfront is usually lost and is replaced bysimultaneous, repetitive, prolonged contractionsof great amplitude that may occur spontaneously.Medical treatment. is usually unavailing althoughsome success has been reported with nitroglycerine.Dilatation has been successful in some patients.Surgical treatment in the form of oesophagomyotomyhas been useful in relieving the symptoms of painand dysphagia.Vigorous achalasia and Chagas disease does notfollbw any classifications. Manometric characterin vigorous achalasia, are simultaneous oesophagealcontractions frequently of high amplitude occur inresponse to swallowing symptomatic disturbance ofoesophageal motility found soon after acute phaseof Chagas disease.