Tertiary Esophageal Contractions: Causes and Treatment
Overview
Tertiary esophageal contractions are nonpropulsive, nonperistaltic contractions that represent an underlying esophageal motility disorder, most commonly associated with gastroesophageal reflux disease (GERD) and may progress to more severe conditions like distal esophageal spasm or achalasia.
Causes and Pathophysiology
Primary Etiologies
Gastroesophageal reflux disease (GERD) is present in up to 58% of patients with tertiary contractions and may play a direct role in inducing abnormal peristaltic activity of the esophageal body 1
Nitric oxide (NO) deficiency resulting in disordered neural inhibition is implicated in the pathogenesis of esophageal spasm disorders that manifest with tertiary contractions 2
Excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions contributes to hypercontractile states 3
Clinical Presentation
Patients typically present with dysphagia, heartburn, and chest pain, though symptoms do not reliably correlate with the severity of nonperistaltic contractions 1
GERD is usually not associated with endoscopic evidence of esophagitis or characteristic symptoms in these patients, making diagnosis challenging 1
The presence of radiologically demonstrable free reflux or heartburn does not predict the presence of GERD on 24-hour pH monitoring 1
Diagnostic Approach
Essential Testing
24-hour ambulatory pH monitoring is the gold standard for detecting GERD in patients with tertiary contractions, as endoscopy and symptoms are unreliable 1
High-resolution esophageal manometry should be performed to characterize the motility disorder and identify associated conditions like nutcracker esophagus, nonspecific esophageal motility disorder, or low lower esophageal sphincter pressure 1
Barium esophagram with videofluoroscopy can identify tertiary contractions, though it lacks sensitivity (only 36-45% show dysmotility on imaging despite manometric abnormalities) 4
Key Diagnostic Pitfall
- Nonsegmental tertiary activity on fluoroscopy may be seen with normal bolus transit and does not always indicate clinically significant dysmotility, whereas segmental tertiary activity with complete luminal obliteration is always associated with disrupted primary peristalsis 5
Treatment Algorithm
First-Line Therapy
Empiric proton pump inhibitor (PPI) therapy should be initiated first, given the high prevalence of GERD (58%) and its role in inducing abnormal esophageal contractions 1, 3
Detection and treatment of GERD may improve symptomatic management even in the absence of typical reflux symptoms 1
Continue PPI therapy for at least 8-12 weeks before assessing response 3
Second-Line Pharmacologic Options
If PPI therapy fails, consider the following agents to reduce contraction vigor:
Calcium channel blockers (e.g., diltiazem, nifedipine) to reduce smooth muscle contractility 2, 3
Long-acting nitrates to promote smooth muscle relaxation 2, 3
Phosphodiesterase-5 inhibitors (e.g., sildenafil) for smooth muscle relaxation 2, 3
Visceral analgesics including tricyclic antidepressants or SSRIs for pain management 2
Important caveat: These medications have suboptimal symptomatic response rates and lack robust randomized controlled trial data 3
Endoscopic Interventions
For refractory cases:
Botulinum toxin injection into the distal esophagus may be effective, though concerns exist regarding post-injection gastroesophageal reflux development 2
Pneumatic dilation has been used with variable response 3
Per-oral endoscopic myotomy (POEM) is emerging as a promising alternative, particularly in patients with associated esophagogastric junction outflow obstruction 2, 3
Surgical Management
Heller myotomy combined with fundoplication remains an option for rare refractory patients who fail medical and endoscopic therapy 2
- POEM may be superior to laparoscopic Heller myotomy for relieving dysphagia, though data are limited 3
Critical Clinical Considerations
Disease Progression
Tertiary contractions can progress to achalasia in some patients, necessitating long-term follow-up 2
Serial manometric studies may be warranted in patients with worsening symptoms 2