What is the recommended management for esophageal dysmotility with stasis in a 91-year-old patient?

Management of Esophageal Dysmotility with Stasis in a 91-Year-Old Patient

For a 91-year-old patient with esophageal dysmotility causing intermittent stasis in the proximal esophagus and throughout the esophageal body, dietary modifications with thickened liquids and small, frequent meals should be the first-line management approach, followed by prokinetic agents if symptoms persist.

Assessment of Current Findings

The patient's findings show:

• Exaggerated impression on the upper esophagus by the aortic arch
• Hypocontractile dysmotility leading to intermittent stasis in the proximal esophagus
• Stasis throughout the majority of the esophagus
• Contents eventually empty into the stomach
• No mass or significant stricture

Management Approach

1. Dietary Modifications (First-Line)

• Thickened liquids: Studies have shown dramatic reduction in aspiration with thickened liquids compared to thin liquids 1

• Consistency modifications:

  • Use nectar-thick or honey-thick liquids rather than thin liquids
  • Avoid straw drinking, which may worsen aspiration risk in elderly patients
  • Consider soft mechanical diet to reduce risk of food bolus obstruction

• Meal pattern adjustments:

  • Small, frequent meals rather than large meals
  • Eat slowly and chew thoroughly
  • Remain upright for 30-60 minutes after eating 2

2. Pharmacological Management (Second-Line)

If dietary modifications are insufficient:

• Prokinetic agents: Consider agents that may improve esophageal transit
• Smooth muscle relaxants: Calcium channel blockers or nitrates may help reduce spasm and improve transit 2
• Low-dose antidepressants: May help modulate visceral hypersensitivity if pain is a predominant symptom 2

3. Swallowing Rehabilitation

• Swallowing exercises: Strengthen the swallowing musculature
  • Shaker exercise (sustained and repetitive head lifts while supine)
  • Masako technique (tongue hold between teeth with dry swallow) 1

4. Monitoring and Follow-up

• Regular follow-up: Monitor for:

  • Weight loss
  • Aspiration pneumonia
  • Nutritional status
  • Symptom progression

• Nutritional assessment: Calculate BMI and percentage weight loss to monitor nutritional status 1

When to Consider More Invasive Options

For this 91-year-old patient, invasive interventions should be considered only if the above measures fail and quality of life is significantly impacted:

• Botulinum toxin injection: Consider if pharmacologic therapy fails (78-89% efficacy for immediate improvement) 2

• Enteral feeding: Consider only if:

  • Significant malnutrition develops
  • Aspiration pneumonia occurs
  • Oral intake becomes unsafe 1

Cautions and Considerations

• Avoid unnecessary medications: Especially those that may worsen dysmotility (opioids, anticholinergics) 1
• Avoid unnecessary procedures: Dilatation is not indicated as there is no stricture 1
• Age consideration: At 91 years, focus on quality of life and symptom management rather than invasive diagnostic or therapeutic procedures
• Risk of aspiration: Monitor closely for signs of aspiration pneumonia, particularly with advanced age and dysmotility

Conclusion

The management of this 91-year-old patient with esophageal dysmotility and stasis should focus on conservative measures that improve symptoms while maintaining quality of life. Dietary modifications and positional changes should be the cornerstone of therapy, with pharmacological interventions as a second step if needed. More invasive procedures should be reserved for cases where conservative management fails and quality of life is significantly impacted.