Esophageal motility disorders

Esophageal symptoms are most often related to gastroesophageal reflux disease and other mucosal or structural processes in the tubular esophagus. When these have been appropriately ruled out with careful endoscopy, or when motility disorders are suspected based on persistent symptoms or endoscopic findings, esophageal motility testing is performed. High resolution manometry has been shown to be superior and has largely replaced conventional esophageal manometry, as it provides more detailed evaluation of esophageal motor function and results in an accurate diagnosis more often. Using innovative and intuitive software tools applied to the electronic pressure data from high resolution manometry, esophageal outflow obstruction (including achalasia spectrum disorders), major motor disorders (hypercontractile esophagus, distal esophageal spasm, and absent contractility), and minor disorders (ineffective esophageal motility and fragmented peristalsis) can be diagnosed. Provocative testing (multiple rapid swallows, rapid drink challenge, and solid test meal) can provide additional gain in motor diagnoses in symptomatic patients with normal or inconclusive standard manometry, but the clinical value is still controversial. New metrics have been introduced to characterize the esophagogastric junction in terms of barrier function and morphology, which are relevant in the context of gastroesophageal reflux disease. Barium radiography has a complementary role in the evaluation and follow-up in patients with symptoms suggestive of esophageal motility disorders. Symptomatic patients with minor motor disorders or normal motility, especially when response to provocative testing is normal, may have a functional basis for symptoms.