Chest Pain, Esophageal Motility Disorder (EMD)

Esophageal Motility Disorder (EMD)

The esophagus is a hollow and muscular tube approximately 25 cm in length, that acts as a conduit to deliver food and other edibles from your mouth to your stomach where the digestion process can begin. If the muscles in your esophagus fail to squeeze properly, they find it difficult to deliver food and liquids into your stomach.

This condition is known as an esophageal motility disorder (EMD) or esophageal dysmotility. EMD refers to a medical disorder, which creates trouble in swallowing, regurgitation of food, and spasm-type pain caused by an allergic reaction to certain foods.

Efficient mobility of edible food and liquid through the esophagus requires a coordinated and sequential motility pattern to push food from the mouth, clear acid and bile reflux from the stomach. Disruption of the highly integrated muscular motion limits delivery of food and fluid, as well as causes a bothersome sense of dysphagia and chest pain.

Types of Esophageal Motility Disorder:

Being an umbrella term, esophageal motility disorder covers all types of swallowing disorders based on their abnormal manometric patterns such as;

1. Primary Disorder (caused by esophageal diseases):

  • Dysphagia
  • Inefficient esophageal motility disorder
  • Nutcracker esophagus
  • Diffuse esophageal spasm
  • Hypertensive lower esophageal sphincter
  • Achalasia

2. Secondary disorder (manifestations of systemic diseases):

  • Diabetes
  • GERD
  • Mellitus
  • Scleroderma

3. Structural (Mechanical) Disorders:

  • Intrinsic
  • Carcinoma and benign tumors
  • Diverticula
  • Eosinophilic esophagitis
  • Esophageal rings and webs (other than the Schatzki ring)
  • Foreign body
  • Lower esophageal (Schatzki) ring
  • Medication-induced stricture
  • Peptic stricture
  • Extrinsic
  • Mediastinal mass
  • Spinal osteophytes
  • Vascular compression

Symptoms of Esophageal Motility Disorder:

Following are the most commonly observed symptoms of esophageal motility disorder;

  • Chest pain
  • Difficulty in swallowing
  • Feel about food stuck in the throat or chest
  • Pressure in the chest after eating
  • Coughing or choking on food
  • Bad breath
  • Acid reflux and heartburn
  • Recurring pneumonia
  • Anxiety
  • Regurgitation (undigested food and fluid for hours after eating)
  • Weight loss and malnutrition
  • Poor sleep

Causes of Esophageal Motility Disorder:

There is no primary cause of esophageal motility disorder but the causes will be specific to the particular condition from which the patient is suffering, from which the most commonly found causes are given as below;

  • Weakened esophageal muscles
  • Immune disorder
  • An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus
  • A nerve or brain problem (stroke)
  • Neurological disorder
  • Neuromuscular disorder
  • Uncoordinated or abnormal muscles in the mouth, throat, or esophagus
  • Benign or malignant strictures
  • Spasms of the esophagus

Diagnosis/Evaluation of Esophageal Motility Disorder:

If a patient is suspected of an esophageal motility disorder, a physician or health care professional has the discretion to perform a series of investigations without having a particular order, based on their experience and the patients’ condition. For this, initially, a general non-invasive investigation is probably chosen to approach the illness. However, the following diagnostic procedure can be used to diagnose esophageal motility disorder;

Esophagography:

It is usually chosen as the first non-invasive investigation process that illustrates the structural and biological functioning of the esophagus. Traditionally, it was not considered a reliable technique to diagnose esophageal varix. But, now esophagography is found a very useful screening examination to determine the relative need for endoscopy and biopsy in patients.  

Manometry:

It is a swallowing test that measures the contraction strength of esophageal muscles in which the normal value must be between 20 to 5000 mmHg/sec/cm. It determines the esophageal capability to transport food and liquid from your mouth to your stomach. This test is usually used for people who have;

Upper Endoscopy:

It is a diagnostic endoscopic procedure that is used to visualize the inner lining of the upper digestive area such as the esophagus, stomach, and duodenum).  Upper endoscopy is performed with an endoscope, a thin and flexible tube that has a small video camera attached to its one end. The tube is placed through your mouth, down your throat, and into your esophagus, stomach, and small intestine. It is the only investigation tool that has both diagnostic and therapeutic benefits to treat esophageal motility disorders.

Esophagography

Manometry

Upper Endoscopy

Purpose:

It evaluates swallowing function, morphologic abnormalities of the pharynx, esophageal motility disorders, and morphologic abnormalities of the esophagus.

It diagnoses and localizes the leak in the esophagus.

It is used to diagnose;

Diffuse esophageal spasm

Achalasia

Scleroderma

Investigate the signs and symptoms, such as nausea, vomiting, abdominal pain, difficulty swallowing, and gastrointestinal bleeding.

Diagnose the diseases and conditions, such as anemia, bleeding, inflammation, diarrhea, or cancers of the digestive system.

Risk Factors:

Problems from radiation exposure

Birth defects

Intestinal issues

Trouble with bowel movements

Pain or swelling of the abdomen

Fever

Gagging when the tube passes into your throat

Watery eyes

Discomfort in your nose and throat

Sore throat

Stuffy nose

Minor nosebleed

Bleeding

Infection

Tearing of the gastrointestinal tract

Treatment/Management of Esophageal Motility Disorder:

Following treatment/management techniques can be applied to patients with suspected esophageal motility disorders;

1. Medical care:

The primary concern with achalasia is that it’s irreversible and incurable. Therefore, a physician or health care professional is striving to control the symptoms and signs when the disease is mild to moderate. Moreover, surgical and endoscopic therapies can also be used to provide relief to the patient for plenty of time.

a. Pharmacological interventions:

If the disease is in the early stages, medicines can be used to get symbolical control over the esophageal motility disorders such as Nitrates along nifedipine. There are some other drugs with limited efficacy that can also be used e.g., anticholinergics, theophylline, beta-2 agonists, phosphodiesterase inhibitors, and nitroglycerin.

b. Endoscopic Therapy:

Esophagogastroduodenoscopy (EGD)/Endoscopic therapy is a non-surgical treatment used to treat the affected area of the digestive tract. Balloon dilation of the lower esophagus can be used to treat the abnormal obstructing sphincter by using the following two less invasive techniques;

  • TTS pneumatic balloon
  • EndoFlip dilation system

Moreover, during EDG, an injection of botulinum toxin can be given to poor surgical patients or their disease is intractable to medical management at the LES or at the site of narrowing.

2. Surgical Care:

Just like balloon dilatation, surgical treatment is targeted at the LES to release the high pressure at the esophagogastric junction (EGJ). Following are the three evidence-based surgical interventions that can be used for severe cases;

  • Heller’s myotomy
  • Extended heller myotomy
  • Esophagectomy with gastric pull-up or intestinal interposition.

Risk of Esophageal Motility Disorder:

People who are already suffering from the following diseases can be at risk of esophageal motility disorder;

  • Benign or malignant strictures.
  • Neurological or neuromuscular disorders.

References:

  • https://gialliance.com/condition/esophageal-motility-disorder/ retrieved on March 2, 2022.
  • https://lluh.org/conditions/esophageal-dysmotility retrieved on March 2, 2022.
  • https://gialliance.com/condition/esophageal-motility-disorder/ retrieved on March 2, 2022.
  • https://ctsurgerypatients.org/lung-esophageal-and-other-chest-diseases/achalasia-and-esophageal-motility-disorders retrieved on March 2, 2022.
  • https://en.wikipedia.org/wiki/Esophageal_motility_disorder#cite_note-:0-5 retrieved on March 2, 2022.
  • https://www.nm.org/conditions-and-care-areas/gastroenterology/spastic-esophageal-motility-disorder/causes-and-diagnoses retrieved on March 2, 2022.
  • https://www.cancer.org/treatment/understanding-your-diagnosis/tests/endoscopy/upper-endoscopy.html#:~:text=An%20upper%20endoscopy%20is%20a,called%20an%20esophagogastroduodenoscopy%2C%20or%20EGD retrieved on March 2, 2022.
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