What is the initial approach to managing a patient with dysphagia and tertiary contractions on an esophagram?

Management of Dysphagia with Tertiary Contractions on Esophagram

Proceed with esophageal manometry to characterize the motility disorder, as isolated tertiary contractions on esophagram rarely indicate a clinically significant motility disorder requiring intervention unless the patient has dysphagia to liquids. 1

Initial Diagnostic Approach

The finding of tertiary contractions on esophagram requires careful clinical correlation before pursuing aggressive workup or treatment:

• Assess dysphagia severity and type: Patients with isolated tertiary waves who have dysphagia to liquids are more likely to have a significant esophageal motility disorder requiring intervention, while those without liquid dysphagia rarely need treatment 1

• Perform high-resolution esophageal manometry: This is the definitive test to characterize the motility disorder, as videofluoroscopy has 80-89% sensitivity and 79-91% specificity for diagnosing esophageal motility disorders compared to manometry 2

• Complete the esophageal evaluation: A biphasic esophagram should evaluate the entire esophagus and gastric cardia, as abnormalities in the mid or distal esophagus can cause referred dysphagia to the pharynx 2, 3

Understanding Tertiary Contractions

Key clinical insight: Tertiary contractions represent nonpropulsive, nonperistaltic esophageal contractions that may or may not indicate pathology:

• When isolated: Only 29% (5 of 17) of patients with isolated tertiary waves on esophagram had a significant esophageal motility disorder on manometry, and only 24% required any intervention 1

• Associated conditions: Tertiary contractions can be associated with gastroesophageal reflux disease (present in 58% of patients with nonpropulsive contractions), nutcracker esophagus, or nonspecific esophageal motility disorder 4

• Oropharyngeal-esophageal connection: 92% of patients with oropharyngeal dysphagia have concomitant esophageal dysfunction (often nonspecific esophageal motility disorder), suggesting that assessment of both phases of swallowing may be necessary 5

Management Algorithm

Step 1: Clinical Triage

• If dysphagia to liquids is present: Proceed directly to high-resolution manometry, as these patients are more likely to have significant motility disorders requiring intervention 1
• If dysphagia to solids only or minimal symptoms: Consider empiric trial of proton pump inhibitor therapy first, given the high prevalence (58%) of gastroesophageal reflux in patients with tertiary contractions 4

Step 2: Manometric Evaluation

• Perform high-resolution manometry to classify the motility disorder according to Chicago Classification 6, 7
• Look for specific patterns: Hypercontractile esophagus (distal contractile integral >8,000 mm Hg·s·cm), diffuse esophageal spasm, or nonspecific esophageal motility disorder 7
• Assess for EGJ outflow obstruction: This finding may identify patients who benefit from endoscopic treatment targeting the esophagogastric junction 7

Step 3: Treatment Based on Findings

If significant motility disorder confirmed on manometry:

• First-line: Empiric trial of proton pump inhibitor therapy, given overlap with gastroesophageal reflux disease 7, 4
• Second-line pharmacologic: Calcium channel blockers, nitrates, or phosphodiesterase inhibitors to reduce contraction vigor, though symptomatic response is often suboptimal 7
• Endoscopic options: Botulinum toxin injection or pneumatic dilation for selected patients, particularly those with EGJ outflow obstruction 7
• Surgical consideration: Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy for relieving dysphagia in hypercontractile disorders 7

If no significant motility disorder or isolated tertiary waves without liquid dysphagia:

• Reassurance and conservative management is appropriate, as intervention is rarely needed 1
• Treat underlying gastroesophageal reflux if present, as this may improve esophageal motor function 4

Critical Pitfalls to Avoid

• Do not assume tertiary contractions always require treatment: The radiologic finding alone does not mandate aggressive intervention without clinical correlation 1

• Do not overlook gastroesophageal reflux: Up to 58% of patients with tertiary contractions have pathologic acid exposure on 24-hour pH monitoring, often without typical reflux symptoms or endoscopic esophagitis 4

• Do not limit evaluation to the esophageal body: Assess both oropharyngeal and esophageal phases of swallowing, as dysfunction in one area frequently coexists with abnormalities in the other 5

• Do not rely on esophagram alone for diagnosis: Manometry is required to definitively characterize motility disorders and guide treatment decisions 2