What is the management for esophageal dysmotility?

From the Guidelines

The management of esophageal dysmotility should prioritize systematic and sufficiently frequent swallowing therapy, making individualized use of different exercises available, as recommended by the ESPEN guideline clinical nutrition in neurology 1. This approach is supported by the fact that exercises and maneuvers probably constitute the most widespread treatment approach for patients with esophageal dysmotility worldwide, with a variety of different interventions existing, ranging from direct to indirect, isolated to combined, and those incorporating swallowing and non-swallowing tasks 1. Some of the exercises that have shown promise in improving esophageal function and reducing symptoms include:

• The Shaker head lift, which has been evaluated in systematic reviews and several RCTs, showing that this treatment improves strengths and endurance of the suprahyoid muscles and upper esophageal sphincter opening 1
• The chin-down technique, which has been shown to reduce aspiration risk by approximately 50% in patients with esophageal dysmotility presenting with aspiration 1
• Tongue strength training, which has been evaluated in some well-done cohort studies, reporting different improvements of swallowing variables like vallecular residues and swallowing safety 1
• Expiratory muscle strength training (EMST), which has shown significant effects on swallowing safety in a RCT in Parkinson patients, and has improved swallowing safety and feeding status in a RCT in subacute stroke patients 1 It is essential to note that the scientific evidence for the efficacy of these exercises is heterogeneous, with a general lack of large RCTs providing clinically meaningful endpoints 1. However, the available evidence suggests that a systematic and individualized approach to swallowing therapy can lead to significant improvements in esophageal function and symptom relief. In addition to these exercises, other treatment approaches, such as the effortful swallow, the Masako maneuver, and the Mendelsohn maneuver, may also be beneficial in certain patients, but the evidence for these approaches is less robust 1. Overall, the management of esophageal dysmotility should be tailored to the individual patient's needs and should involve a multidisciplinary approach, including swallowing therapy, lifestyle modifications, and, in some cases, medication or more invasive interventions.

From the Research

Management of Esophageal Dysmotility

The management of esophageal dysmotility involves various treatment options, including:

• Medical therapy with agents that reduce esophageal contractile force, such as anticholinergic agents, nitrates, and calcium antagonists 2
• Pneumatic balloon dilation therapy, which is considered more effective than medical therapy for achalasia 2, 3
• Botulinum toxin injection, which has been suggested as a therapeutic option for achalasia patients with good results on lower esophageal sphincter pressure and symptom scores 2
• Endoscopic management, including peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy (G-POEM), which are recommended for carefully selected patients with achalasia and gastroparesis, respectively 3
• Prokinetic agents, such as serotonergic agents (e.g., buspirone, mosapride, and prucalopride), which have been shown to improve parameters of esophageal motility, although the effect on symptoms is less clear 4, 5

Treatment Options for Specific Conditions

• Achalasia: pneumatic balloon dilation therapy, botulinum toxin injection, and POEM are recommended treatment options 2, 3
• Diffuse esophageal spasm: calcium channel antagonists may be beneficial, at least in some patients 2
• Hypercontractile esophagus: calcium channel antagonists may be effective in reducing esophageal contractile force, but the clinical effect is limited 2
• Ineffective esophageal motility: prokinetic agents, such as serotonergic agents, may be prescribed as first-line pharmacologic intervention, although the beneficial effects are limited 5

Pharmacologic Interventions

• Nifedipine, a calcium-channel blocker, has been shown to decrease lower esophageal sphincter pressure and contraction amplitude in the esophageal body, and may have a role in the treatment of motility disorders of the lower esophageal sphincter or esophageal body 6
• Buspirone, a serotonin receptor agonist, has been suggested as a potential treatment option for ineffective esophageal motility, although further research is needed to evaluate its effectiveness 4, 5