Assessment and Management of Severe Esophageal Dysmotility with Proximal Retention
This patient requires high-resolution esophageal manometry as the definitive next diagnostic step, followed by consideration of endoscopic or surgical myotomy if achalasia or clinically relevant esophagogastric junction outflow obstruction is confirmed. 1, 2, 3
Diagnostic Workup Algorithm
Immediate Next Steps
High-resolution manometry (HRM) is mandatory to definitively classify the esophageal motility disorder using Chicago Classification criteria, as VFSS findings of severe dysmotility with proximal retention suggest either achalasia, esophagogastric junction outflow obstruction, or absent contractility 1, 2, 3, 4
Timed barium esophagram should be obtained as an adjunctive test to assess esophageal emptying and retention quantitatively, particularly useful when HRM findings are inconclusive or to guide treatment decisions 2, 5
Upper endoscopy with biopsies at two levels is essential to exclude structural causes (malignancy, strictures, eosinophilic esophagitis) that can mimic or coexist with primary motility disorders 1, 6, 4
Why HRM is Critical Here
Dysphagia to both solids AND liquids from the outset indicates a motor problem rather than mechanical obstruction, making manometry the gold standard diagnostic test 1, 2, 5
VFSS has only 80-89% sensitivity for esophageal motility disorders compared to manometry, and cannot subtype achalasia (Types I, II, III) which directly impacts treatment selection 1, 6, 2
Proximal esophageal retention specifically suggests achalasia or severe esophagogastric junction outflow obstruction, conditions requiring definitive intervention at the lower esophageal sphincter 2, 3, 5
Management Strategy Based on Manometry Results
If Achalasia is Confirmed
Endoscopic myotomy (POEM) or surgical myotomy (Heller) should be strongly considered as first-line durable treatment, as these provide superior long-term outcomes compared to medical therapy 2, 3, 4
Pneumatic dilation is an alternative endoscopic option for patients who are not surgical candidates or prefer less invasive approaches 3, 4
Botulinum toxin injection is reserved only for patients unfit for definitive therapy, as it provides temporary relief and may complicate subsequent myotomy 3, 4
If Esophagogastric Junction Outflow Obstruction is Found
Determine clinical relevance before invasive treatment by correlating manometric findings with symptom severity, timed barium esophagram retention, and consideration of functional lumen imaging probe (EndoFLIP) to assess distensibility 2, 3, 4
Endoscopic or surgical myotomy should be considered only if clinically relevant obstruction is confirmed, as many manometric diagnoses apart from achalasia are clinically irrelevant 3, 4
If Absent Contractility or Other Peristaltic Disorders are Identified
Lifestyle and dietary modifications are first-line, including eating slowly, chewing thoroughly, drinking liquids with meals, and avoiding large meals before bedtime 2, 5
Pharmacologic therapy has weak evidence: calcium-channel blockers, nitrates, phosphodiesterase-5 inhibitors, or peppermint oil may be tried but have limited efficacy 4
Invasive treatment is generally not recommended for peristaltic disorders other than achalasia unless there is clear clinical correlation and failure of conservative measures 3, 4
Critical Pitfalls to Avoid
Do not rely on VFSS alone for treatment decisions in esophageal dysmotility, as it cannot provide the precise manometric diagnosis required to guide invasive interventions 1, 6, 2
Do not initiate invasive treatment without confirming clinical relevance, as manometric abnormalities may not correlate with symptoms, particularly in disorders other than achalasia 3, 4
Do not miss structural causes by skipping endoscopy, as malignancy, strictures, and eosinophilic esophagitis can present with similar symptoms and VFSS findings 1, 6, 4
Avoid treating proximal retention with esophageal dilation, as this is ineffective for primary motility disorders and the problem lies at the esophagogastric junction, not the proximal esophagus 1, 2, 3
Additional Considerations
Aspiration Risk Assessment
Silent aspiration occurs in 55% of patients with aspiration, so the absence of coughing does not rule out aspiration risk in this patient with severe retention 7
Dietary modifications and swallowing therapy should be implemented if aspiration is documented on VFSS, working with a speech-language pathologist to optimize swallowing safety 1, 4
Nutritional Support
- Assess nutritional status and consider temporary enteral feeding if oral intake is severely compromised by retention and aspiration risk, as maintaining nutrition is critical while pursuing definitive diagnosis and treatment 1