Esophageal Motility Disorders Clinical Presentation

Updated: Sep 12, 2016
  • Author: Eric A Gaumnitz, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Presentation

History

Achalasia

Note the following:

  • Progressive dysphagia for both solids and liquids is the hallmark of achalasia. Dysphagia for solids is more common than for liquids.
  • Retrospectively, symptoms are present on average as long as 6 years prior to presentation.
  • Regurgitation of food retained in the proximal dilated esophagus is a common occurrence, especially at night, requiring patients to sleep using multiple pillows or upright in a chair. This symptom worsens as the esophagus dilates with time.
  • Chest pain may be another early symptom, characterized by a squeezing retrosternal pain radiating to the neck, jaw, arms, or back. The chest pain may worsen with food and can awaken patients from sleep.
  • A sensation of heartburn may be reported by 30% of patients and is assumed to be related to retained food fermentation and lactic acid.
  • Emotional stress or rapid eating may worsen all of the symptoms described above.
  • Weight loss is common with achalasia; however, the loss is usually slight.

Spastic esophageal motility disorders

Chest pain is the hallmark of spastic esophageal motility disorders, although patients with spastic esophageal motility disorders also may report dysphagia. Similar to the chest pain of achalasia, it may mimic angina. The mechanism is not clear but may be related to transient esophageal muscle ischemia, luminal distension, or altered visceral sensation.

Dysphagia is not necessarily related to chest pain. Dysphagia for solids and liquids is a common symptom and especially seen in DES. Dysphagia may be intermittent and nonprogressive in nature, typically not prolonging mealtime or causing weight loss.

Patients also commonly report heartburn, regurgitation, or other esophageal complaints of reflux disease due to ineffective acid clearance from the esophagus.

Weight loss is common with achalasia; however, the loss is usually slight.

Scleroderma esophagus

Scleroderma involves the esophagus in more than 75% of patients, regardless of clinical type. Two forms of this disease exist–(1) progressive systemic sclerosis (PSS), characterized by diffuse scleroderma, and a more fulminant form with early involvement of internal organs or (2) CREST syndrome, characterized by calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia. The severity of esophageal involvement does not correlate necessarily with severity of involvement of other organs. In fact, dysphagia may be the presenting clinical symptom in some patients.

The esophageal symptoms of scleroderma usually reflect the severity of acid reflux disease, including heartburn, regurgitation, and dysphagia.

Erosive esophagitis is observed in as many as 60% of patients, and the incidence of Barrett esophagus and adenocarcinoma of the esophagus is increased.

Dysphagia usually is due to diminishing peristalsis, peptic strictures, or a combination of both.

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Physical Examination

In patients with primary motility disorders, results of a physical examination often are unrevealing.

Clinical signs of scleroderma in the proper clinical setting must be noted, especially skin changes.

A bedside swallowing challenge may be performed with a glass of water.

Evaluate the patient's general nutrition and hydration status if significant dysphagia is reported.

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