Esophageal motility disorders (Distal esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter): Modern management

Abstract

The group of hypercontractile esophageal motility disorders includes distal esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive lower esophageal sphincter (LES). The clinical relevance of these abnormalities identified during esophageal manometry is debated, and their management can be challenging. Hypercontractile esophageal motility abnormalities are defined through specific manometric criteria. Current pathophysiologic concepts for these abnormalities include defects in the nitronergic neural pathways and imbalances between the cholinergic and nitronergic pathway. Proposed treatments for NE, DES, and hypertensive LES include proton-pump inhibitors, nitrates, calcium channel blockers, phosphodiasterase inhibitors, and tricyclic antidepressants or serotonin reuptake inhibitors. Small case series reported benefits after botulinum toxin injections, dilatations, and myotomies. The optional management of esophageal spasm, NE, and hypertensive LES is still debated. Treatment recommendations are based on controlled studies with small numbers of patients or on case series. Medical treatment, including acid suppression, smooth muscle relaxants, and visceral analgesics, should be tried first. In nonresponding patients, botulinum toxin injections or balloon dilatations can be tried. Pneumatic dilatations or myotomies should be regarded as last-option treatments for nonresponding patients.

Relationship between manometric findings and reported symptoms in nutcracker esophagus: insights gained from a review of 313 patients

“…This in agreement with our findings that HTN-LES was associated with CP in patients with NE. Others have also reported an overlap between NE and HTN-LES [3]. NE has previously been linked to HTN-LES, with an incidence of NE in 13-56% of HTN-LES patients [2,4,10,20,21].…”

“…According to a new classification system, NE, together with a hypertensive lower esophageal sphincter (LES), belongs to the category of hypercontractile motility disorders of the esophagus [3].…”

Congenital oesophageal stricture in anArabian filly treated by balloon dilation

“…) were other possible differential diagnoses but were ruled out by the CT scan and the improvement observed in the last endoscopy. A spasmotic dysfunction of the oesophagus causing chest pain and dysphagia is described in human patients (Tutuian and Castell ). This condition is not congenital and its aetiology is unclear although abnormalities in endogenous nitric oxide function are suspected.…”

Discrete responses of myenteric neurons to structural and functional damage by neurotoxins in vitro

“…BtxA injection is presently used in the gastrointestinal tract for purposes such as the treatment of achalasia, hypercontractile esophageal motility disorders, and anal fissures, where it is assumed to cause a decrease in efferent activity of cholinergic nerves, as it does elsewhere in the nervous system (24). The mechanism of action on enteric nerve function has not been studied, but is thought to involve entry of BtxA into neurons after binding to the synaptic vesicle protein SV2 during its exposure to the external medium.…”