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esophageal motility disorder
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esophageal motility disorder

  I have been having a problem with esophageal dismotility for the last 6 years.  I am 46 and had some problems with acid reflux all my life.  This motility began with a felling like something was stuck in my upper throat and a tightness in swallowing.  My doctor initially put me on prilosec but the feeling remained even after weeks of treatment with prilosec.  Finally a gastroenterologist performed an endoscopy and found nothing.  He put me on cardizem.  This provided some relief.  After a few months they did a Bernstein-Motility study.  This showed that I had some problem with hypertensive lower esophageal sphincter.  I continued the treatment with cardizem.  Also with this study they did perform a dilatation with a long tube.  I don't think this helped.  My question is:  how effective would other dilations be?  The medication helps some and there have been times when I haven't needed them.  But it's really acting up again with the choking sensation in the upper throat.  My doctor doesn't believe dilations will help.  Thank you!
Dear Mike,
The symptoms that you describe could certainly be caused by a hypermotility disorder of the esophagus, of which one type is  hypertensive lower esophageal sphincter (LES (The LES is the muscle at the lower end of the esophagus that relaxes as you swallow to allow food to enter the stomach, but then contracts to prevent reflux of gastrii ccontents back ibnto the chest)).  Hypertensive LES is, as the name implies, is a condition associated with increased LES pressure but normal relaxation with swallowing.  The negative endoscopy is the rule for this disorder but is a necessary test to rule out alternative explanations for your symptoms, such as esophagitis or esophageal stricture.  Esophageal manometry is the crucial test to make the diagnosis.  The Bernstein test is used to determine if acid reflux into the esophagus is the cause of symptoms.  A small amount of diluted acid solution is instilled into the esophagus to see if this reproduces symptoms.  However, the provocation of pain is too independent of motor events to clarify the role of hypermotility in symptom production.
The good news is that hypertensive LES is not progressive or fatal and, in most cases, can be managed medically.  Calcium channel blockers such as Cardizem have been successful in some patients, as you have experienced.  Usually, calcium channel blockers are considered an alternative to nitrate preparations, another class of smooth muscle relaxants.  For example, a medication called Isosorbide dinitrate can be taken under the tongue when symptoms are present or taken in a long-acting formulation when symptoms are more consistent.  Low-dose antidepressant medications have also been proven effective.  A controlled trial with trazodone hydrochloride (Desyrel) at 100 to 150 mg/day produced global improvement and reduced distress from esophageal symptoms.
Esophageal dilation is generally thought to be ineffective.  However, in patients with severe abnormalities on manometry, pneumatic (or balloon) dilation reportedly improves dysphagia (difficulty swallowing) in 40% of patients.  This method of treatment is typically reserved for a subgroup of patients with documented incomplete relaxation of the LES by manometry.  Long esophagomyotomy (incision of the muscle of the esophagus) has also been used successfully in severe cases.  Success rates have been reported to exceed 50%.  This drastic intervention, however, is reserved for patients in whom manometry has convincingly documented abnormal motor activity during an attack of pain.
This response is offered for your general information and should not replace the conclusions drawn from a careful and complete evaluation by your physician.
If you want, we would be happy to see you in the Division of Gastroenterology at Henry Ford Hospital and perform the appropriate investigations after we have had the chance to meet you and to review your history in greater detail. You can arrange an appointment with Dr. Zonca, one of our experts in the diagnosis and treatment of esophageal motility disorders by calling the Henry Ford Physician Referral Line at (800)653-6568.
*keywords: esophageal motility

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