How should esophageal dysmotility be treated, including non‑pharmacologic measures, pharmacologic therapy, and indications for endoscopic or surgical intervention?

Treatment of Esophageal Dysmotility

Begin with high-resolution manometry to classify the specific motility disorder pattern, as treatment differs fundamentally between disorders of esophagogastric junction outflow (achalasia spectrum) versus disorders of peristalsis (spasm, hypercontractility, ineffective motility). 1

Initial Diagnostic Algorithm

Before initiating treatment, complete the following workup:

• Perform biphasic barium esophagram first, which has 80-89% sensitivity for detecting motility disorders and is superior to endoscopy for visualizing functional abnormalities 1
• Conduct upper endoscopy with biopsies at distal, mid, and proximal esophagus to exclude eosinophilic esophagitis, structural lesions, and mucosal disease that can mimic dysmotility 2, 1
• Review all medications systematically, particularly opioids, cyclizine, and anticholinergics which commonly cause esophageal dysmotility 1
• Obtain high-resolution manometry with solid swallows (not just water swallows) to replicate actual eating symptoms and unmask pathology 2, 3

Treatment Based on Motility Disorder Type

For Achalasia and EGJ Outflow Obstruction

Pursue definitive mechanical intervention rather than pharmacotherapy, as medical treatment is clearly inferior to pneumatic dilation or myotomy. 4

• Per-oral endoscopic myotomy (POEM) is the preferred treatment for type III achalasia (achalasia with spasm) and select cases of refractory distal esophageal spasm 1, 3
• POEM should only be performed by experienced operators in high-volume centers (20-40 procedures needed for competence) 1
• Counsel patients about 20-40% risk of post-POEM reflux esophagitis requiring indefinite PPI therapy and potential surveillance endoscopy 1
• For patients unsuitable for POEM, consider laparoscopic fundoplication with partial wrap preferred if esophageal hypomotility is present 2

For Spastic Disorders (Distal Esophageal Spasm, Hypercontractile Esophagus)

Start with smooth muscle relaxants and neuromodulators before considering invasive interventions, as these disorders are often self-limited and may have functional overlay. 3, 5

Pharmacological First-Line:

• Initiate PPI therapy (omeprazole 20-40 mg twice daily) especially when GERD symptoms coexist, which is common 2, 1, 3
• Trial calcium channel blockers (diltiazem 30-60 mg before meals) or long-acting nitrates for smooth muscle relaxation, though clinical benefit is limited despite manometric improvement 1, 4
• Consider baclofen (GABA-B agonist) 5-20 mg three times daily for regurgitation or belch-predominant symptoms, monitoring for CNS and GI side effects 2, 1, 3

Neuromodulation for Hypersensitivity Component:

• Add low-dose tricyclic antidepressants (amitriptyline 10-25 mg at bedtime, titrate to 50 mg) for chest pain or esophageal hypersensitivity 1
• Refer for cognitive behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing when hypervigilance or psychological factors contribute 2, 1, 3

Endoscopic Intervention:

• Botulinum toxin injection (40 mg in four quadrants) is effective for esophageal spasms failing pharmacotherapy 1, 3
• Reserve POEM for highly selected refractory distal esophageal spasm cases after exhausting medical options 1, 3

For Ineffective Esophageal Motility and Absent Contractility

Focus on acid suppression and treating concurrent gastroparesis rather than attempting to improve contractility directly. 2, 1

• Prescribe PPI therapy as these patients often have concurrent GERD that worsens symptoms 2, 1
• Assess for delayed gastric emptying with gastric emptying scintigraphy if symptoms suggest gastroparesis 2
• Consider prokinetics only if documented gastroparesis is present, as they have not shown benefit for esophageal dysmotility alone 2
• Avoid laparoscopic Nissen fundoplication; if anti-reflux surgery is necessary, use partial fundoplication to minimize postoperative dysphagia risk 2

For Eosinophilic Esophagitis with Dysmotility

Treat the underlying eosinophilic inflammation first with topical steroids or dietary elimination before considering dilation. 2, 1

• Start topical budesonide (1 mg twice daily mixed with sucralose) or fluticasone (880 mcg twice daily swallowed) for 8-12 weeks 2
• Perform follow-up endoscopy with biopsies at 8-12 weeks to assess histological response, as symptoms do not correlate with mucosal healing 2, 1
• If stricture or narrowing persists despite histological remission, perform balloon dilation to 15-18 mm using gradual increments 2, 1
• Continue maintenance topical steroids or dietary elimination indefinitely after dilation to prevent recurrence 1

Management of Refractory Symptoms Despite Optimization

If symptoms persist after appropriate pharmacotherapy:

• Obtain ambulatory 24-hour pH-impedance monitoring on PPI to determine if ongoing acid/non-acid reflux, reflux hypersensitivity, or behavioral disorders (rumination, supragastric belching) explain symptoms 2
• Repeat high-resolution manometry with solid swallows if not previously performed, as this increases diagnostic yield 2, 3
• Reassess for esophageal hypersensitivity or hypervigilance and intensify neuromodulator therapy or behavioral interventions 2

Special Considerations for Post-Surgical Dysmotility

Post-Fundoplication Dysphagia:

• Perform endoscopy, manometry, pH studies, and barium swallow to assess wrap integrity before intervention 2
• Consider balloon dilation to 30-40 mm for post-Nissen dysphagia if wrap is intact 2
• Treat concurrent delayed gastric emptying to reduce need for repeat dilations 2

Anastomotic Strictures:

• Use bougie or balloon dilation as first-line, aiming for 15-18 mm diameter 2
• Consider steroid injection (triamcinolone 40 mg/mL in four quadrants) immediately before dilation for refractory strictures, though this increases candidiasis risk 2
• Needle knife incision in four quadrants is equally safe as dilation in experienced hands and maintains luminal patency in 61.5% at 12 months versus 19.8% with continued dilation alone 2

Critical Pitfalls to Avoid

• Do not perform invasive interventions for hypercontractile disorders without exhausting medical therapy and behavioral interventions, as these are often self-limited and may have functional components 5
• Do not miss opioid-induced esophageal dysmotility, which is increasingly prevalent and can mimic achalasia 5
• Do not rely on symptoms alone to assess treatment response in eosinophilic esophagitis; 41% report symptomatic improvement without histological response 2
• Do not perform total fundoplication in patients with documented esophageal hypomotility or impaired peristaltic reserve; use partial wrap instead 2
• Do not use H2-receptor antagonists for maintenance after Schatzki ring dilation; they are ineffective compared to PPIs 6