What are the implications of intermittent tertiary esophageal contractions with mild esophageal dysmotility (dysmotility) and associated intraesophageal reflux up to the thoracic inlet level?

From the Guidelines

Intermittent tertiary esophageal contractions with mild esophageal dysmotility and associated intraesophageal reflux up to the thoracic inlet level require a comprehensive approach, focusing on lifestyle modifications and medication therapy, prioritizing proton pump inhibitors (PPIs) as the first line of treatment, as suggested by the most recent guidelines 1.

Condition Overview

This condition involves abnormal esophageal contractions combined with reflux that extends high into the esophagus, potentially leading to various symptoms and complications. The management of such a condition should aim at reducing symptoms, preventing further complications, and improving the patient's quality of life.

Management Approach

The management approach should be multifaceted, including:

• Lifestyle Modifications: Elevating the head of the bed by 6-8 inches, avoiding eating within 3 hours of bedtime, eliminating trigger foods (such as caffeine, alcohol, spicy/fatty foods, and chocolate), wearing loose clothing around the waist, and maintaining a healthy weight.
• Medication Therapy: Starting with a proton pump inhibitor (PPI) such as omeprazole 20mg once daily before breakfast for 8 weeks. If nighttime symptoms persist, supplementing with an H2 blocker like famotidine 20mg before dinner can be considered.

Considerations for Treatment

• PPI Therapy: The use of PPIs is supported by recent clinical practice updates 1, which emphasize their role in managing symptoms associated with gastroesophageal reflux disease (GERD), including extraesophageal manifestations.
• Dose Adjustment: If symptoms persist after 8 weeks of therapy, considering increasing the PPI dose or switching to esomeprazole 40mg daily may be necessary, as guided by the patient's response and the severity of symptoms.
• Prokinetic Agents: For patients with persistent symptoms, prokinetic agents like metoclopramide might be considered, but their use should be discussed with the patient due to potential side effects.

Multidisciplinary Approach

Given the potential for extraesophageal symptoms and the complexity of diagnosing and managing EER, a multidisciplinary approach involving gastroenterology, otolaryngology, pulmonology, and other relevant specialties is crucial for optimal patient care, as highlighted in recent expert reviews 1. This collaborative approach ensures that all possible contributions to the patient's symptoms are considered and addressed appropriately.

Outcome Prioritization

The primary goal of the management strategy is to improve the patient's quality of life by reducing symptoms and preventing complications, thereby minimizing morbidity and mortality associated with the condition. This approach is in line with the latest clinical practice updates and guidelines, which prioritize patient-centered outcomes and comprehensive care 1.

From the Research

Implications of Intermittent Tertiary Esophageal Contractions

• Intermittent tertiary esophageal contractions with mild esophageal dysmotility and associated intraesophageal reflux up to the thoracic inlet level can have several implications for patients with gastroesophageal reflux disease (GERD) symptoms 2.
• Esophageal dysmotility is almost universal after esophageal atresia repair and is mainly related to the developmental anomaly of the esophagus, which can lead to numerous symptoms and comorbidities associated with esophageal atresia 3.
• The management of esophageal dysmotility in patients with esophageal atresia is essentially based on treatment of associated inflammation related to peptic or eosinophilic esophagitis 3.
• A substantial percentage of patients with suspected proton pump inhibitor-resistant nonerosive reflux disease had primary esophageal motility disorders, highlighting the importance of esophageal manometry in diagnosing and managing these patients 4.

Diagnostic and Therapeutic Approaches

• Multimodality evaluation, including esophageal manometry, ambulatory esophageal pH monitoring, and gastric emptying scanning, can change the diagnosis and guide therapy in more than one third of patients with persistent GERD symptoms despite empiric proton pump inhibitor therapy 2.
• Effortful swallow has been shown to affect esophageal physiology and may offer a behavioral manipulation of the esophageal phase of swallowing, with potential clinical applications for treating esophageal dysmotility 5.
• Tailoring antireflux surgery to esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia, and the Toupet procedure has been shown to be as effective as the Nissen procedure in controlling reflux with a lower rate of dysphagia 6.

Pathophysiology and Characterization

• High-resolution esophageal manometry has facilitated the characterization of esophageal dysmotility, but there is an incomplete correlation between symptoms and manometrical patterns, highlighting the need for further research into the pathophysiology of esophageal dysmotility 3.
• Impedance coupled to high-resolution esophageal manometry may help predict the clinical outcome and personalize patient management, particularly in patients with esophageal atresia 3.
• Nonacidic reflux and weakly acidic reflux are important contributors to the symptoms of patients with proton pump inhibitor-resistant nonerosive reflux disease, and 24-hour esophageal impedance and pH monitoring is invaluable for assessing symptom-reflux associations 4.