1. Esophageal motor disorders
Prof.Dr.Khalid A. Jasim Al-Khazraji
MBCHB , MD, CABM , FRCP , FACP

2. Diffuse esophageal spasm
- DES: Is a motility disorder of the esophagus that usually produces episodes of chest pain & intermittent dysphagia to both solids and liquids.
- Present in late middle age.
- Associated with degeneration of the nerves in Auerbach’ plexus (like achalasia). It can rarely evolve to achalasia.
Clinical features:-
1- Retrosternal chest pain (mimic angina).
2- Dysphagia.
3- Can be secondary to GERD.
Investigations:-
1-Barium swallow: appearance of “corkscrew” esophagus.
2-Esophageal manometry: multipeaked and repetitive contractions.

4. Treatment - Therapy is principally supportive and empirical.
- Recommendation of benign nature of the disease.
Trial of smooth muscle relaxants (e.g. Isosorbid 10mg,
nifedipine 10mg). Or
Trial of antidepressant (e.g. amitriptyline 25 to 75 mg at
bedtime, imipramine 25 to 50 mg at bedtime).
- Relaxation exercise and psychological counseling are
helpful.
- PPIs may be successful if DES is secondary to GERD.
- Occasionally , balloon dilation or even longitudinal myotomy is necessary.

5. Systemic sclerosis
Esophagus is the most GIT organs affected in scleroderma.
Cause dysphagia , regurgitation, heartburn. When dysphagia for solid is prominent, is likely reflects a peptic stricture or adenocarcinoma in Barrett’s esophagus.
Manometry: show characteristic low LES pressure and weak aperistaltic contractions in the smooth muscle part of esophageal body.
Treatment is as for reflux and benign stricture.

6. Nutcracker esophagus
-Term given to a relatively common manometric pattern found in patients with non-cardiac chest pain.
-This pattern consist of normal peristalses but with contractions of very high amplitude (average more than 180 mm Hg).
- It causes dysphagia, to both solid and liquid foods, and chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age, but is more common in the 6th and 7th decades of life
-Patients with nutcracker esophagus and chest pain commonly exhibit symptoms and signs of depression or anxiety.
-Treatment: 1- (amitriptyline 25 to 75 mg at Bedtime), (imipramine 25 to 50 mg at bedtime) and trazodone (50 mg three times a day), or 2- alprazolam (0.25 to .0.5 mg three times a day) and clonazepam ( 0.5 to 1 mg twice a day) may relieve chest pain.

7. Time space graph of normal peristalsis
Time space graph of normal peristalsis. Nutcracker esophagus shows higher amplitude contractions (Z-axis) that take longer to pass (X-axis).
Data recorded at Department of Gastro - Enterology, University Hospital of Zurich, Switzerland

8. Pharyngoesophageal Diverticulum
Diverticulum: is a pouch or a sac arising
From a tubular organ.
Three types:
1- Zenker’s diverticulum
2-Mid-esophageal and epiphrenic diverticula
3-Esophageal intramural pseudodiverticulosis

9. Zenker’s diverticulum
Is an outpouching of pharyngeal mucosa in
an area of muscular weakness (killian’s
triangle) just proximal to cricopharyngeus
muscle (UES).
It’s acquired, typically manifesting in seventh
and eight decades of life.
When large it leads to dysphagia, regurgitation
of undigested food, halitosis, neck pain, and
swelling, and aspiration. Large diverticulum
May manifest as a mass in the lest side of the
neck that enlarge or produce noises (gurgles)
with eating.
Diagnosis: by barium swallow.
Treatment: cricopharyngeal myotomy with or without diverticulectomy.

10. Atlas of Zenker’s diverticulum-

11. Mid-esophageal and epiphrenic diverticula
- Uncommon.
Arise either from pulsation, such as esophageal motor disorder, or by traction , such a paraesophageal inflammatory or neoplastic disease.
Most are small. Wide-mouthed outpouchings and are asymptomatic.
When large leads to dysphagia, regurgitation, aspiration , or chest pain.
Diagnosis: barium swallow or endoscopy.
Treatment: surgical diverticulectomy.

12. Esophageal intramural pseudodiverticulosis
Uncommon condition. Etiology: not clear.
Mostly found in middle-age patients
Are 1-4 mm flask-shaped outpouchings that protrude from the lumen into the esophageal wall.
They are dilated excretory ducts of esophageal submucosal glands , hence they are not true diverticula.
Produce no symptoms, but occur in the setting of chest pain, dysphagia, heartburn, and Odynophagia, reflecting the associated underlying disease.
Diagnosis: barium swallow, on endoscopy it seen as pinpoint openings in the esophageal wall.
Treatment: directed at the underlying disease

13. Esophageal rings - Distal esophageal rings are of two types:
1- The A ring (muscular): is broad 4-5 mm band of hypertrophied muscle covered by squamous epithelium.
it’s rare and usually asymptomatic.
when associated with dysphagia, it can be treated by bougienage or by endoscopic injection with botulinum toxin.
2- The B ring ( mucosal) ( Schatzki’s ring): is thin 2 mm membrane consisting of mucosa and submucosa located at the squamocolumnar junction.
it’s common and often asymptomatic.
Are probably congenital in origin.
When ring constrict the lumen to less than 15 mm, dysphagia occur.
Diagnosis : barium swallow.
Treatment: when symptomatic by esophageal bougienage.

14. Atlas of Esophageal rings

15. Esophageal web
Are thin, fragile membrane of stratified squamous epithelium that occur in the upper and mid esophagus.
These congenital anomalies rarely encircle the lumen but instead protrude, as a shelf, from the anterior wall.
Usually asymptomatic & diagnosed incidentally by barium swallow.
Can cause dysphagia for solids only.
When symptomatic treated by esophageal bougienage.
Cervical web + dysphagia + iron deficiency anaemia ; are part of Plummar - Vinson or Paterson-Kelly syndrome.

16. Thank you 2015