What is the significance of tertiary esophageal contractions?

From the Guidelines

Tertiary esophageal contractions are abnormal, uncoordinated contractions of the esophagus that have significant clinical importance as they indicate esophageal dysmotility. These contractions are non-propulsive, disorganized muscle movements that occur spontaneously rather than in response to swallowing. They are most commonly seen in elderly patients and those with gastroesophageal reflux disease (GERD). The significance of tertiary contractions lies in their association with dysphagia (difficulty swallowing) and chest pain that can mimic cardiac conditions. Some key points to consider about tertiary esophageal contractions include:

• They represent a breakdown in the normal peristaltic wave pattern of the esophagus, often due to degenerative changes in the myenteric plexus or esophageal smooth muscle.
• Management typically involves treating underlying conditions like GERD with proton pump inhibitors, although the provided evidence does not directly discuss the treatment of tertiary esophageal contractions 1.
• The provided evidence discusses oesophageal dilatation in clinical practice, which may be relevant for some patients with esophageal dysmotility, but it does not specifically address tertiary esophageal contractions 1.
• Patients with persistent symptoms despite medical therapy may require further evaluation with manometry to assess for more serious motility disorders.
• Lifestyle modifications including eating smaller meals, avoiding trigger foods, and remaining upright after eating are also important components of management. It is essential to note that the provided evidence does not directly address the significance of tertiary esophageal contractions, but it discusses oesophageal dilatation in clinical practice, which may be relevant for some patients with esophageal dysmotility 1.

From the Research

Tertiary Esophageal Contractions

• Tertiary esophageal contractions, also known as nonpropulsive esophageal contractions, are abnormal contractions of the esophagus that can lead to impaired acid clearance and gastroesophageal reflux (GER) 2.
• These contractions can be radiologically described as tertiary contractions or "corkscrew" esophagus and may suggest the presence of an underlying motility disorder 2.
• Studies have shown that up to 58% of patients with nonpropulsive esophageal contractions on esophagography have GER, which may play a role in the induction of abnormal peristaltic activity of the esophageal body 2.

Correlation with Esophageal Motility Disorders

• The correlation between tertiary waves on esophagrams and findings on high-resolution esophageal manometry has been assessed, and it was found that an isolated finding of tertiary waves on an esophagram is rarely associated with a significant esophageal motility disorder that requires intervention 3.
• However, patients with isolated tertiary waves who required intervention had a dysphagia to liquids, suggesting that tertiary contractions, in the absence of dysphagia to liquids, indicate no significant esophageal motility disorder 3.
• Other studies have characterized manometry and barium as complementary diagnostic approaches for distal esophageal spasm, a rare motility disorder presenting principally with nonobstructive dysphagia and noncardiac chest pain 4.

Clinical Significance

• Tertiary esophageal contractions can be associated with dysphagia, heartburn, and chest pain, but the symptoms or severity of nonperistaltic contractions do not correlate with GER 2.
• Radiologically demonstrable free reflux or the presence of heartburn does not predict GER, and 24-hour pH monitoring is necessary to diagnose GER in patients with nonpropulsive esophageal contractions 2.
• The dysphagia sensation experienced by many patients may result from a normal or supernormal contraction wave pushing the bolus against resistance, and a deeper understanding of the distensibility of the bolus-containing esophageal segment during peristalsis holds promise for the development of innovative medical and surgical therapies to effectively address dysphagia 5.

Treatment and Management

• A long esophageal myotomy with an antireflux procedure has been shown to be a valid treatment alternative in appropriately selected patients with diffuse esophageal spasm, with significant improvement in symptoms and reduction in the amplitude of esophageal body contractions 6.
• Esophagectomy and colon interposition is the procedure of choice in patients with multiple previously failed myotomies 6.