What are the treatment options for esophageal dysmotility?

From the Guidelines

Treatment of esophageal dysmotility should prioritize symptom management and addressing the underlying cause, with a focus on lifestyle modifications and medications tailored to the specific type of dysmotility, as recommended by recent guidelines 1.

Initial Treatment

Initial treatment typically includes lifestyle modifications such as:

• Eating smaller, more frequent meals
• Avoiding lying down after eating for 2-3 hours
• Elevating the head of the bed by 6-8 inches
• Avoiding trigger foods like caffeine, alcohol, chocolate, and fatty or spicy foods Medications are often prescribed based on the specific type of dysmotility, with prokinetic agents like metoclopramide or erythromycin for hypomotility disorders, and smooth muscle relaxants like calcium channel blockers or nitrates for spastic disorders.

Medications and Interventions

For hypomotility disorders, prokinetic agents like metoclopramide (10mg before meals and at bedtime) or erythromycin (250mg three times daily before meals) can help improve esophageal contractions 1. For spastic disorders, smooth muscle relaxants such as calcium channel blockers (nifedipine 10-30mg daily) or nitrates (isosorbide dinitrate 5-10mg three times daily) may be beneficial 1. Acid suppression with proton pump inhibitors like omeprazole (20-40mg daily) or pantoprazole (40mg daily) is often added to prevent reflux complications, as supported by recent guidelines 1. For severe cases unresponsive to medical therapy, endoscopic interventions such as botulinum toxin injection (100 units) into the lower esophageal sphincter or surgical myotomy may be necessary, with per-oral endoscopic myotomy (POEM) being a viable option for carefully selected patients with esophageal dysmotility, as suggested by recent clinical practice updates 1.

Key Considerations

• Regular follow-up is essential to monitor symptoms and adjust treatment as needed.
• Treatment effectiveness varies based on the specific dysmotility disorder, with some conditions responding better to therapy than others.
• The role of POEM for non-achalasia spastic motility disorders is not well-defined, and less invasive alternatives should be exhausted before consideration of POEM in very selected cases 1.

From the Research

Treatment Options for Esophageal Dysmotility

• Medical treatment of esophageal disorders with esophageal hyper- or dysmotility requires agents that reduce esophageal contractile force, such as anticholinergic agents, nitrates, and calcium antagonists 2
• Calcium channel antagonists, alone or in combination with anticholinergics or nitrates, can be used as a medical trial, especially in mild achalasia 2
• Botulinum toxin injection can be used as a therapeutic option in achalasia patients, with good results on lower esophageal sphincter pressure (LESP) and symptom scores 2
• Pneumatic balloon dilation therapy is a commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients 3
• Laparoscopic Heller myotomy is a minimally invasive and effective treatment option for patients with achalasia, with low morbidity and mortality rates 4
• Lifestyle and dietary modifications, oral pharmacologic therapy, and various endoscopic or surgical interventions can be used to manage esophageal motility disorders, depending on the type and severity of the disorder 5

Specific Treatments for Achalasia

• Graded approach to pneumatic dilation using Rigiflex balloons is a commonly used nonsurgical means of treating patients with achalasia 3
• Surgical myotomy, including laparoscopic Heller myotomy, is a effective treatment option for patients with achalasia, with similar efficacy to pneumatic dilation 3, 4
• Botulinum toxin injection of the lower esophageal sphincter (LES) can be used as a therapeutic option in achalasia patients who cannot undergo balloon dilation or surgery 3, 2

Diagnosis and Management of Esophageal Motility Disorders

• High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders 5, 6
• The Chicago Classification v4.0 provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach 6
• Patient-reported outcomes (PROs) have a critical role in providing patient-centered care and should be used to assess symptoms and treatment outcomes 6