What are the treatment options for esophageal motility disorders?

Treatment of Esophageal Motility Disorders

The treatment of esophageal motility disorders should be tailored to the specific disorder type, with per-oral endoscopic myotomy (POEM) being the preferred intervention for achalasia, while non-achalasia spastic disorders should only undergo POEM after less invasive approaches have been exhausted. 1

Diagnostic Approach

• High-resolution manometry (HRM) is essential for accurate diagnosis of esophageal motility disorders, providing superior assessment of bolus movement and detecting abnormalities that may be missed with standard manometry 2
• HRM enables classification of achalasia into subtypes (I, II, and III), which has prognostic value and guides therapeutic decisions 2
• Adjunctive testing during HRM (larger volumes of water, solid/viscous swallows, or test meals) can unmask pathology not seen with standard water swallows 2
• Complete evaluation should include esophagogram, endoscopy, manometry, and pH monitoring to establish a comprehensive diagnosis 1

Treatment Options by Disorder Type

Achalasia

• First-line interventions:

  • Per-oral endoscopic myotomy (POEM) is highly effective for achalasia with success rates >90% 1
  • For type III achalasia, myotomy should be tailored to the proximal extent of esophageal body spasm rather than confined to the LES alone 1
  • POEM provides the advantage of unlimited proximal extension of myotomy compared to laparoscopic approaches 1

• Alternative options:

  • Pneumatic dilation achieves good results in >80% of cases and is an alternative to POEM 3
  • Laparoscopic Heller myotomy combined with fundoplication is effective in >80% of patients 4
  • Botulinum toxin injection can be considered for patients who are poor candidates for more invasive procedures 5

Non-achalasia Spastic Disorders (Diffuse Esophageal Spasm, Nutcracker Esophagus)

• Conservative approach first:

  • Pharmacological therapy with calcium channel antagonists, nitrates, or anticholinergics should be tried initially 5
  • Neuromodulators (low-dose antidepressants) can be beneficial for patients with esophageal hypersensitivity 1

• Invasive interventions:

  • Laparoscopic myotomy is preferred over thoracoscopic approach for diffuse esophageal spasm (DES), with >80% symptom relief 4
  • Extended esophageal myotomy can relieve symptoms in approximately 75% of patients with DES or symptomatic nutcracker esophagus 3
  • Surgical outcomes for nutcracker esophagus are less predictable and often disappointing compared to other motility disorders 4

Esophagogastric Junction Outflow Obstruction (EGJOO)

• Comprehensive evaluation with correlation of symptoms is mandatory before intervention 1
• POEM should only be considered on a case-by-case basis after less invasive approaches have been exhausted 1
• Long-term success rates for POEM in EGJOO (80-85%) appear somewhat lower compared to POEM for classic achalasia subtypes 1

Behavioral and Adjunctive Therapies

• Cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing can be beneficial for patients with functional components 1
• For patients with reflux hypersensitivity or esophageal hypervigilance, neuromodulation with low-dose antidepressants should be considered 1

Treatment Algorithm

1. Confirm diagnosis with HRM, endoscopy, and other appropriate studies

2. For achalasia:

   • POEM or laparoscopic Heller myotomy as first-line therapy
   • Pneumatic dilation as an alternative
   • Botulinum toxin for poor surgical candidates

3. For non-achalasia spastic disorders:

   • Begin with pharmacological therapy (calcium channel blockers, nitrates)
   • If medication fails, consider POEM or surgical myotomy
   • Add neuromodulators if hypersensitivity is suspected

4. For EGJOO:

   • Exhaust medical therapy and botulinum toxin before considering POEM
   • Carefully select patients for invasive interventions

Important Considerations and Pitfalls

• Symptoms alone are unreliable in distinguishing motility disorders from GERD; objective testing is essential 4
• Check for electrolyte abnormalities (particularly magnesium and potassium) which can affect esophageal motility 2
• Post-treatment follow-up should include both symptom assessment and objective testing, as symptoms may not correlate with physiological improvement 1
• Minimally invasive surgical approaches are generally superior to medical therapy for primary esophageal motility disorders 6