eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Motility Disorders: Follow-up

Author: Eric A Gaumnitz, MD, Professor of Medicine, Division of Gastroenterology, University of Wisconsin School of Medicine; Program Director, Gastroenterology and Hepatology Fellowship, University of Wisconsin School of Medicine and Public Health; Director, Motility Unit, University of Wisconsin Hospitals
Coauthor(s): Abdullah Fayyad, MD, MBBS, Gastroenterology Staff, Private Practice, Digestive and Liver Disease Consultants
Contributor Information and Disclosures

Updated: Aug 29, 2009

Follow-up

Further Outpatient Care

  • Patients require outpatient follow-up care.
    • Changes in medical therapy often are needed, and, with progression of disease, alternative endoscopic or surgical interventions might be needed.
    • Good planning and awareness of complications mandate multidisciplinary follow-up care, involving primary care, gastroenterology, dietary, and surgery services as needed.

Transfer

  • Patients with achalasia, DES, or other motility disorders who need aggressive endoscopic or surgical interventions should be referred to centers with experienced gastrointestinal and surgical services.
  • Gastroenterologists dealing with such disease processes should be familiar with performance and interpretation of diagnostic and therapeutic procedures. This also is true for surgeons, who need to be familiar with the surgical intervention involved.

Complications

  • Achalasia and squamous cell carcinoma
    • With achalasia, the risk of squamous cell carcinoma of the esophagus is higher than that of the general population.
    • No studies to date have shown convincing evidence that surveillance is worthwhile.
    • Pathogenesis is not well documented, but chronic mucosal irritation is incriminated.
    • Squamous cell carcinoma usually develops several years after the diagnosis of achalasia. The risk typically starts increasing after approximately 10 years of having the disease process.
    • At the time of diagnosis, the esophagus usually is dilated, and the tumor is advanced.

Prognosis

  • Achalasia
    • Achalasia is a progressive disease that requires chronic therapy. Depending on the rate and extent of disease progression, therapy might include endoscopic and surgical interventions.
    • Advanced achalasia can lead to malnutrition, dehydration, and aspiration.
    • Even after therapy, patients continue to have mild symptoms related to aperistaltic esophagus and, thus, will want to still follow careful eating habits.
  • Scleroderma esophagus
    • Scleroderma is a systemic disease with a progressive nature.
    • Systemic complications are the major cause of mortality.
    • Significant acid reflux might lead to disabling symptoms, caused by reflux or its complications.
  • Spastic esophageal motility disorders
    • Whether or not symptomatic relief is achieved, prognosis in patients with spastic esophageal motility disorders is favorable.
    • Life expectancy is not affected, and weight loss is rare.
    • If symptoms progress, then workup should be repeated because DES can progress to achalasia.

Patient Education

  • Patients should be counseled about their disease. They should be well informed about its lifelong nature. Possible complications, therapeutic options, expected outcomes, and dietary modifications should be explained.
  • Reassurance is important in patients with spastic motility disorders, especially in the setting of noncardiac chest pain.
  • For excellent patient education resources, visit eMedicine's Heartburn/GERD/Reflux Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Reflux Disease (GERD) and Heartburn.

Miscellaneous

Medicolegal Pitfalls

  • The most important medicolegal issues in regard to esophageal motility disorders are chest pain and pseudoachalasia.
    • Chest pain: A cardiac origin for chest pain should be ruled out by thorough workup before the pain can be attributed to an esophageal etiology. Always remember that coronary artery disease is far more common than esophageal motility disorders, and coronary artery disease is a major killer when compared to esophageal motility disorders, which are chronic nonfatal diseases in general.
    • Pseudoachalasia: A clinical, radiologic, and manometric picture of achalasia does not rule out another etiology at the gastroesophageal junction that produces a similar presentation. The etiology that is most concerning is adenocarcinoma of the gastroesophageal junction. Upper endoscopy almost always is necessary to rule out a malignant etiology in all patients diagnosed with achalasia.

Special Concerns

  • Presbyesophagus
    • Presbyesophagus is a radiographic term used to define asymptomatic peristaltic abnormalities in elderly patients. Manometry studies show motility disorders, including failed peristalsis, decreased LES relaxation, and increased spontaneous contractions. Symptoms correlate poorly with peristaltic abnormalities.
    • Studies that exclude comorbidities, including diabetes mellitus and neurologic diseases, show a normal peristaltic pattern in elderly patients, except for some decreased amplitude. This suggests that comorbidities associated with older age are responsible for these peristaltic abnormalities.
  • Diabetes mellitus
    • Esophageal dysmotility is observed in more than one half of the patients with diabetic neuropathy and, occasionally, is observed in the absence of demonstrable neuropathy.
    • Reported manometric abnormalities include hypotensive peristalsis, frequent failed peristalsis, and hypotensive LES with impaired deglutitive relaxation. Simultaneous contractions and repetitive contractions also are reported. These changes are thought to be secondary to autonomic neuropathy. The significance of these findings is uncertain because most of these patients are asymptomatic.
  • Alcoholism: Esophageal peristaltic dysfunction and reflux are frequent in patients with alcoholism. High-amplitude contractions (>150 mm Hg) in the middle third of the esophagus seem to be a marker of excessive alcohol consumption. The esophageal peristaltic abnormalities tend to improve with abstinence.
  • Psychiatry patients: A higher incidence of esophageal motility disorders occurs among patients undergoing psychiatric care, especially patients with anxiety and depressive disorders. Contraction abnormalities reflect a functional motor impairment, which might be related to the effect of psychiatric medications. Upper endoscopy usually produces normal results in these patients.
 


More on Esophageal Motility Disorders

Overview: Esophageal Motility Disorders
Differential Diagnoses & Workup: Esophageal Motility Disorders
Treatment & Medication: Esophageal Motility Disorders
Follow-up: Esophageal Motility Disorders
Multimedia: Esophageal Motility Disorders
References
Further Reading
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Further Reading

Related eMedicine Topics

Clinical Trials
 National Guideline Clearinghouse

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Keywords

esophageal motility disorders, esophageal motility dysfunction, esophagus dysfunction, esophageal peristalsis dysfunction, esophageal peristalsis, achalasia, dysphagia, gastrointestinal motility, primary spastic esophageal motility disorders, diffuse esophageal spasm, DES, nutcracker esophagus, hypertensive lower esophageal sphincter, hypertensive LES, presbyesophagus, lower esophageal sphincter dysfunction, scleroderma esophagus, spastic motility disorder of the esophageal body, Heller myotomy, esophagectomy

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Contributor Information and Disclosures

Author

Eric A Gaumnitz, MD, Professor of Medicine, Division of Gastroenterology, University of Wisconsin School of Medicine; Program Director, Gastroenterology and Hepatology Fellowship, University of Wisconsin School of Medicine and Public Health; Director, Motility Unit, University of Wisconsin Hospitals
Eric A Gaumnitz, MD is a member of the following medical societies: American Gastroenterological Association, American Motility Society, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Abdullah Fayyad, MD, MBBS, Gastroenterology Staff, Private Practice, Digestive and Liver Disease Consultants
Abdullah Fayyad, MD, MBBS is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

Medical Editor

Ronnie Fass, MD, Director of GI Motility Laboratory, Tucson VA Medical Center, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of Arizona School of Medicine
Ronnie Fass, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Motility Society, American Society for Gastrointestinal Endoscopy, and Israel Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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