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Primary Esophageal Motility Disorders

2001; Elsevier BV; Volume: 76; Issue: 2 Linguagem: Inglês

10.4065/76.2.195

1942-5546

Douglas G. Adler, Yvonne Romero,

Esophageal and GI Pathology

Esophageal motility disorders often manifest with chest pain and dysphagia. Achalasia is a disorder of the lower esophageal sphincter and the smooth musculature of the esophageal body. In achalasia the lower esophageal sphincter typically fails to relax with swallowing, and the esophageal body fails to undergo peristalsis. In contrast to spastic disorders of the esophagus, achalasia can be progressive and cause pronounced morbidity. Pseudoachalasia mimics achalasia in terms of symptoms but can be caused by infectious disorders or malignancy. Treatment for achalasia is nonstandardized and includes medical, endoscopic, and surgical options. Spastic disorders of the esophagus, such as diffuse esophageal spasm and nutcracker esophagus, and nonspecific esophageal motility disorder are benign and nonprogressive, with similar findings on esophageal manometry. Although the exact cause remains unknown, these disorders may represent a manifestation of gastroesophageal reflux disease. Treatment of spastic disorders includes medical and surgical approaches and is aimed at symptomatic relief. Esophageal motility disorders often manifest with chest pain and dysphagia. Achalasia is a disorder of the lower esophageal sphincter and the smooth musculature of the esophageal body. In achalasia the lower esophageal sphincter typically fails to relax with swallowing, and the esophageal body fails to undergo peristalsis. In contrast to spastic disorders of the esophagus, achalasia can be progressive and cause pronounced morbidity. Pseudoachalasia mimics achalasia in terms of symptoms but can be caused by infectious disorders or malignancy. Treatment for achalasia is nonstandardized and includes medical, endoscopic, and surgical options. Spastic disorders of the esophagus, such as diffuse esophageal spasm and nutcracker esophagus, and nonspecific esophageal motility disorder are benign and nonprogressive, with similar findings on esophageal manometry. Although the exact cause remains unknown, these disorders may represent a manifestation of gastroesophageal reflux disease. Treatment of spastic disorders includes medical and surgical approaches and is aimed at symptomatic relief. Dysphagia and chest pain are symptoms encountered frequently in general medical practice. When episodes of chest pain are accompanied by dysphagia and cardiac sources of the pain have been excluded by formal testing, the esophagus often becomes the primary focus of investigation. Gastroesophageal reflux disease (GERD) can sometimes be implicated as the cause of such symptoms, and spastic disorders of the esophageal body or motor disorders of the lower esophageal sphincter (LES) should be included in the differential diagnosis even though they occur less frequently than such entities as GERD. Although there are many disorders of esophageal motility, including nonspecific esophageal motility disorder (NSMD), achalasia, diffuse esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive LES, this article focuses on the 3 most studied: achalasia, DES, and NE. Nonspecific esophageal motility disorder will be discussed briefly. The diagnosis of NSMD is often used in the evaluation of a patient with dysphagia and/or chest pain who has abnormal findings on esophageal motility tracing but does not fulfill the fixed criteria for other discrete diagnoses. The only required finding for NSMD is “Peristaltic abnormalities of insufficient severity to establish any [other] diagnosis, yet not felt to be normal.”1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar The list of associated findings for NSMD includes contractions that are variously nontransmitted, retrograde, repetitive, high amplitude, low amplitude, prolonged, or spontaneous. Incomplete LES relaxation can also be seen in patients with NSMD. These findings can be found in any combination. Treatment of NSMD is nonstandardized at present, and treatment decisions are often aimed at symptomatic relief and guided by the dominant pattern (spastic, hypocontractile, etc) seen during esophageal manometry. Achalasia is a disorder of both the LES and the smooth musculature of the esophageal body. In patients with achalasia, the primary problems are a failure of the LES to relax completely during swallowing and a failure of the esophageal smooth muscle to produce peristalsis adequately.2Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders.Surg Clin North Am. 1997; 77: 971-992Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The definitive cause of achalasia remains unknown, but the disorder is postulated to result from smooth muscle denervation in the esophagus. Achalasia is most commonly idiopathic but has also been strongly associated with Chagas disease as a result of infection by Trypanosoma cruzi.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar Like DES and NE, achalasia manifests clinically with the symptoms of chest pain and dysphagia. Unlike DES and NE, achalasia may become progressively severe. Often achalasia is associated with more serious complications such as weight loss, regurgitation of undigested food, and episodes of aspiration pneumonia, all of which are due to failure of swallowed solids and liquids to pass adequately into the stomach. Foods remain in the esophagus for varying durations until they either pass into the stomach or are regurgitated. Patient reports of awakening with undigested food on the pillow should raise suspicions of severe difficulty with esophageal clearance. Achalasia should not be confused with hypertensive LES syndrome, in which manometry shows an increased resting pressure in the LES but normal LES relaxation with swallowing. The classic manometric finding in achalasia is a lack of primary peristalsis (aperistalsis). Other associated findings include an increased resting LES pressure (although some patients with achalasia have a normal resting LES pressure)3Katz PO Achalasia.in: Castell DO Richter JE Dalton CB Esophageal Motility Testing. Elsevier, New York, NY1987: 107-117Google Scholar and incomplete or only brief LES relaxation in response to a wet swallow (also known as premature LES closure). These manometric findings are highly reproducible in contrast to manometric findings in patients with DES or NE. A subset of patients may have high-amplitude simultaneous and repetitive contractions on manometry, and they are classified as having so-called vigorous achalasia.2Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders.Surg Clin North Am. 1997; 77: 971-992Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Achalasia is most commonly assessed by using a barium swallow test. Typical findings include a dilated esophagus with a fluid level and a tapering of the distal esophagus to a narrow “bird beak-like” configuration (Figure 1). The tapered end of the esophagus reflects an LES that fails to relax in the presence of esophageal contents. Esophageal dilation in achalasia can be impressive and the course of the esophagus through the chest tortuous. Retained food can often be seen admixed with oral contrast. Aperistalsis can be appreciated on fluoroscopy.4Ott DJ Motility disorders of the esophagus.Radiol Clin North Am. 1994; 32: 1117-1134PubMed Google Scholar An important aspect to remember in the evaluation of barium studies in patients suspected to have achalasia is that several conditions can mimic its appearance. Most notably, intrinsic and extrinsic neoplasms of the esophagus, stomach, and mediastinum can produce so-called pseudoachalasia. Indeed, when a patient presents with signs and symptoms of achalasia, pseudoachalasia due to tumor must be included in the differential diagnosis.4Ott DJ Motility disorders of the esophagus.Radiol Clin North Am. 1994; 32: 1117-1134PubMed Google Scholar Other disorders, such as Chagas disease, leiomyomas, leiomyosarcomas, and benign esophageal strictures, can also produce radiographic findings that mimic primary achalasia. Upper endoscopy in patients suspected of having achalasia will often confirm findings reflected on barium studies, such as retained food and esophageal dilation. In such patients, endoscopy is often useful for detecting the presence or absence of malignancy. Suspicious lesions can sometimes be identified, and patients who appear to have extrinsic compression of the esophagus should be referred for more definitive imaging via endoscopic ultrasonography (EUS) or computed tomography. Even though EUS has been used to evaluate patients with known or suspected achalasia, experts state that interpretation of such images is difficult and subject to error.5Van Dam J Endosonographic evaluation of the patient with achalasia.Endoscopy. 1998; 30: A48-A50PubMed Google Scholar Unlike DES and NE, achalasia is associated with the development of esophageal carcinoma, usually squamous cell carcinoma. In a large population-based study of 1062 patients with achalasia, a 16-fold risk of esophageal cancer was found. Despite this finding, aggressive screening has not been advocated because of the low absolute risk of esophageal cancer among patients with achalasia.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar, 6Sandler RS Nyren O Ekbom A Eisen GM Yuen J Josefsson S The risk of esophageal cancer in patients with achalasia: a population-based study.JAMA. 1995; 274: 1359-1362Crossref PubMed Google Scholar Pharmacology.-Medications have a minimal role in the treatment of achalasia. As in DES and NE, nitrates and calcium channel antagonists are of limited use, and adverse effects are common; however, these agents can decrease LES pressure. Some patients report improvement with sub-lingual forms of nifedipine or nitrates.7Gelfond M Rozen P Gilat T Isosorbide dinitrate and nifedipine treatment of achalasia: clinical, manometric and radionuclide evaluation.Gastroenterology. 1982; 83: 963-969Abstract Full Text PDF PubMed Scopus (217) Google Scholar Botulinum toxin, directly injected into the LES under endoscopic guidance, has been shown to reduce LES pressure significantly in humans and animals.8Pasricha PJ Ravich WJ Hendrix TR Sostre S Jones B Kalloo AN Intrasphincteric botulinum toxin for the treatment of achalasia [published correction appears in N Engl J Med. 1995;333:75].N Engl J Med. 1995; 332: 774-778Crossref PubMed Scopus (507) Google Scholar The duration of the effect of botulinum toxin varies, and many patients undergo repeated injections on an as-needed basis. These repeated injections can lead to LES scarring and may complicate future myotomy.9Patti MG Way LW Evaluation and treatment of primary esophageal motility disorders.West J Med. 1997; 166: 263-269PubMed Google Scholar Botulinum toxin should be used preferentially in frail and elderly patients because they tend to have a prolonged response and surgery can be avoided.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar Dilation.-Esophageal dilation has been a mainstay in the treatment of achalasia for literally hundreds of years. Esophageal dilation of the LES for achalasia can be performed under endoscopic and/or fluoroscopic guidance with either solid or pneumatic dilators that are substantially larger than standard esophageal dilators. Dilators or balloons of increasing size can be used during the same session, but care must be exercised because of the risk of perforation and bleeding. Reported clinical response to dilation therapy varies widely, but approximately 60% to 80% of patients will experience improvement after 1 session.2Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders.Surg Clin North Am. 1997; 77: 971-992Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Duration of response is also highly variable, and many patients need intermittent dilations indefinitely. Surgery.-Originally described by Heller,10Heller E Extramuköse cardioplastik beim chronischen cardiospasmus mit dilatation des oesophagus.Mitt Grenzeg Med Chir. 1913-1914; 27: 141-149Google Scholar surgical myotomy of the LES has been modified over the past several decades and can now be performed laparoscopically. Regardless of the specifics, with all myotomies, 1 or more incisions are made at the gastroesophageal junction to sever the muscle fibers causing esophageal blockage. Modern myotomies are sometimes performed concurrently with an antireflux procedure (fundoplication) to prevent long-term complications, but the type of antireflux procedure performed varies with regional surgical practice. The only prospective randomized trial that compared dilation to surgical myotomy found that 40 (95%) of 42 patients treated with myotomy were almost symptom free at a mean of 5 years, while only 20 (51%) of 39 patients in the dilation group fared as well.11Csendes A Braghetto I Henriquez A Cortes C Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia.Gut. 1989; 30: 299-304Crossref PubMed Scopus (389) Google Scholar However, not all patients are surgical candidates, and surgical myotomy has associated risks. Recurrent dysphagia can develop many years after myotomy as a consequence of either scarring or an incomplete initial myotomy. Summary.-Oral agents for achalasia are of limited use, whereas dilation and botulinum toxin can produce a more sustained response. Botulinum toxin may be useful for elderly patients or poor surgical candidates. Surgical myotomy should be reserved for refractory cases and should be performed via a minimally invasive approach when possible. Diffuse esophageal spasm is characterized clinically by intermittent chest pain and dysphagia. Chest pain can vary from mild to crushing, extend to the back and jaw, and last from seconds to minutes. The pain with DES does not always occur with swallowing. Regurgitation is infrequent. Dysphagia in patients with DES can be due to solids or liquids and often occurs more commonly with ingestion of either very cold or very hot foods. The classic abnormality seen during esophageal manometry in patients with DES is a pattern of abnormal simultaneous contractions of the esophageal body. These must be present in greater than 30% of wet swallows during formal testing to make a confident diagnosis. The symptoms of DES can range from mild to severe but are classically intermittent. Minor manometric diagnostic criteria for DES include frequent, repetitive esophageal contractions (=3 peaks) of a high amplitude (>180 mm Hg) that are prolonged (>6 seconds). The LES can occasionally have high baseline pressure in DES but is usually normal, as is the upper esophageal sphincter.12Chen YM Ott DJ Hewson EG et al.Diffuse esophageal spasm: radiographic and manometric correlation.Radiology. 1989; 170: 807-810PubMed Google Scholar Nutcracker esophagus, which also classically presents with chest pain and dysphagia, is characterized manometrically by a mean distal esophageal peristaltic amplitude of more than 180 mm Hg. Minor criteria for NE include repetitive contractions (>2 peaks) that are prolonged (>6 seconds). The LES relaxes normally but has an elevated baseline pressure of greater than 40 mm Hg.4Ott DJ Motility disorders of the esophagus.Radiol Clin North Am. 1994; 32: 1117-1134PubMed Google Scholar In both DES and NE symptoms can be intermittent, may or may not occur with eating, and are typically not progressive. This lack of symptomatic and manometric progression separates DES and NE from other esophageal causes of chest pain and angina, such as achalasia and esophageal cancer.4Ott DJ Motility disorders of the esophagus.Radiol Clin North Am. 1994; 32: 1117-1134PubMed Google Scholar The similarities between the diagnostic criteria for these 2 entities are striking. The diagnosis of DES is made by using a combination of clinical and manometric criteria, while the diagnosis of NE is based on manometry alone. The issue of whether DES and NE in fact represent the same entity has been raised repeatedly. In addition, many patients will have esophageal contractions on manometry that are clearly abnormal (intense, prolonged, etc), but such contractions do not meet criteria for DES or NE (or even achalasia). In such patients NSMD may be diagnosed, and how this diagnosis differs from DES and NE remains unclear. Of note, healthy patients can have abnormally intense or prolonged contractions on manometry without having any symptoms. This finding reflects some of the limitations of esophageal manometry as a diagnostic tool. For both DES and NE, the specific pathophysiology remains elusive and has led some investigators to question whether these are real disorders or are simply collections of symptoms and manometric findings.13Valori RM Nutcracker, neurosis, or sampling bias?.Gut. 1990; 31: 736-737Crossref PubMed Scopus (30) Google Scholar This concern is especially prevalent among esophagologists with regard to NE because the manometric findings of NE can often be seen in healthy patients without dysphagia. The classic finding of DES, most commonly seen during a barium swallow study, is the “corkscrew” or “rosary-bead” appearance of the esophageal body during a simultaneous contraction (Figure 2). Primary (normal) peristalsis is often seen in the upper one third of the esophagus, and so-called tertiary (abnormal) activity is seen in the region of the spasm. Tertiary activity can occasionally be seen in normal subjects. Episodes of pain do not always correlate with spastic esophageal contractions, and patients can feel intense pain even when swallows appear radiographically normal. In NE, findings on barium swallows are often normal. Various nonspecific forms of tertiary activity have been reported; however, NE is a manometric, not a radiological, diagnosis.14Ott DJ Esophageal motility disorders.Semin Roentgenol. 1994; 29: 321-331Abstract Full Text PDF PubMed Scopus (5) Google Scholar The esophagus is usually normal in appearance in patients with DES and NE, but a thorough search for signs of GERD (esophagitis, ulcerations, stricture, etc) should be performed at the time of upper endoscopy. Recently, EUS was used to determine whether patients with NE have a thickened esophageal muscularis propria, as this finding was often cited in older studies. In 2 studies15Melzer E Tiomny A Coret A Bar-Meir S Nutcracker esophagus: severe muscular hypertrophy on endosonography.Gastrointest Endosc. 1995; 42: 366-367Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 16Melzer E Ron Y Tiomni E Avni Y Bar-Meir S Assessment of the esophageal wall by endoscopic ultrasonography in patients with nutcracker esophagus.Gastrointest Endosc. 1997; 46: 223-225Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar of a total of 18 patients with spastic disorders of the esophagus that fulfilled criteria for both DES and NE, a slight but statistically significant trend toward thickening of the muscularis propria was found. Still, the width of the muscularis propria in these patients did not correlate with the frequency or duration of symptoms. Thus, at present, EUS does not seem to have a specific role in the evaluation of DES and NE. The issue of whether NE represents a manifestation of GERD has been raised because of the frequency of abnormal esophageal pH test results in a large proportion of patients. In 1 study of 20 patients with a diagnosis of NE who underwent pH testing, abnormal reflux was noted in 13 patients, and 1 had erosive esophagitis detected on upper endoscopy. Thus, 14 patients (70%) were thought to have GERD. Of these 14 patients, 12 were enrolled in an open-label treatment trial with either histamine receptor antagonists or proton pump inhibitors, 10 (83%) of whom experienced significant reduction in the frequency of painful episodes, the number of days with pain, and pain severity. Of these 10 patients, only 2 had normalization on manometry, a finding arguing against hypertensive esophageal contractions as the sole cause of pain.17Achem SR Kolts BE Wears R Burton L Richter JE Chest pain associated with nutcracker esophagus: a preliminary study of the role of gastroesophageal reflux.Am J Gastroenterol. 1993; 88: 187-192PubMed Google Scholar Given the fact that NE may not be a clinical entity distinct from DES, DES might represent a manifestation of GERD. These issues have implications for treatment, as discussed subsequently. General Guidelines.-Of importance, both DES and NE are usually nonprogressive disorders that are not thought to be related to more serious medical problems. Reassurance is a pillar of therapy. Treatment should be aimed at symptomatic relief once cardiac disease has been excluded definitively through formal testing. Patients may experience spontaneous improvement or resolution of symptoms in the absence of treatment. The incidence of psychiatric disorders is increased in patients with spastic abnormalities of the esophagus. Specifically, anxiety, depression, and somatoform disorders are seen more commonly in this patient group compared with controls.2Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders.Surg Clin North Am. 1997; 77: 971-992Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 18Just RJ Castell DO Chest pain of undetermined origin.Gastrointest Endosc Clin N Am. 1994; 4: 731-746PubMed Google Scholar While this does not necessarily imply a cause-and-effect relationship, comorbid psychiatric disorders should be considered when these patients are being evaluated. The association between spastic disorders of the esophagus and certain psychiatric conditions may represent sample bias. For example, patients with somatoform disorders often present to physicians with various complaints (including chest pain), and extensive testing can sometimes disclose esophageal abnormalities. Pharmacology.-Muscle relaxants such as nitrates, calcium channel antagonists, and even botulinum toxin have been used to treat DES and NE, with various results. Although many small series and anecdotal reports have described good clinical response with these agents, no long-term outcome studies exist to confirm their efficacy. Adverse effects (hypotension, headache, etc) can be severe. Of note, 1 open-label study that evaluated the use of diltiazem in patients with acute symptoms found that patients had good symptomatic improvement in chest pain and dysphagia, but this has not been proved in a placebo-controlled study.19Richter JE Spurlin TJ Cordova CM Castell DO Effects of oral calcium blocker, diltiazem, on esophageal contractions: studies in volunteers and patients with nutcracker esophagus.Dig Dis Sci. 1984; 29: 649-656Crossref PubMed Scopus (96) Google Scholar The anxiolytic trazodone is the only agent that has been shown to improve symptoms of spastic disorders of the esophagus in a single prospective, blinded, controlled study.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar A strong argument can be made that antireflux agents (predominantly histamine receptor antagonists and proton pump inhibitors) should be included in the pharmacologic armamentarium used to treat DES and NE and that they should be used early in the course of disease. As mentioned previously, DES and NE may represent manifestations of GERD, and treatment of GERD has been shown to have clinical effect. In addition, antireflux therapy for these patients has been shown to diminish unexplained chest pain regardless of whether patients had any motility tracing abnormalities.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar Another theory for the use of antireflux agents early in the treatment of DES and NE (before use of smooth muscle relaxants) stems from the concept that smooth muscle relaxants might decrease LES pressure and thus paradoxically worsen reflux.17Achem SR Kolts BE Wears R Burton L Richter JE Chest pain associated with nutcracker esophagus: a preliminary study of the role of gastroesophageal reflux.Am J Gastroenterol. 1993; 88: 187-192PubMed Google Scholar Endoscopy.-Esophageal dilation, predominantly done via bougienage, has been used in patients with NE, but results have been disappointing. Indeed, studies attempting to treat NE with bougienage have shown no pronounced symptomatic improvement and have only manifested a trend toward a placebo effect.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar, 2Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders.Surg Clin North Am. 1997; 77: 971-992Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Pneumatic dilation has shown promising results in patients with DES in retrospective, uncontrolled studies and thus can be considered; however, the decision of where to dilate the balloon in the esophagus is difficult.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar Duration of symptomatic improvement is highly variable. Endoscopic application of botulinum toxin for DES and NE has not been studied adequately to make definite conclusions about its efficacy. Surgery.-The traditional surgical approach to spastic disorders of the esophagus has been esophageal myotomy. Myotomy performed either laparoscopically or thoracoscopically is primarily reserved for patients with DES or NE in whom medical therapy has failed. Several important points should be remembered when surgical myotomy is being considered in patients with DES or NE. First, myotomy will decrease only the intensity of esophageal contractions, not the frequency; thus, symptoms may still occur after surgery. Second, myotomy can lead to a hypocontractile esophagus, which can result in dysphagia (a symptom the operation is meant to improve). Third, the chest pain that occurs with DES and NE responds better to myotomy than does the dysphagia associated with these illnesses. Finally, a trial of antisecretory agents should be tried before surgical myotomy is considered because the procedure may prove to be unnecessary.20McBride PJ Hinder RA Filipi C Raiser F Katada N Lund RJ Surgical treatment of spastic conditions of the esophagus.Int Surg. 1997; 82: 113-118PubMed Google Scholar To date, only small studies of myotomy for spastic disorders of the esophagus have been reported,21Eypasch EP DeMeester TR Klingman RR Stein HJ Physiologic assessment and surgical management of diffuse esophageal spasm.J Thorac Cardiovasc Surg. 1992; 104: 859-868PubMed Google Scholar, 22Filipi CJ Hinder RA Thoracoscopic esophageal myotomy—a surgical technique for achalasia diffuse esophageal spasm and “nutcracker” esophagus.Surg Endosc. 1994; 8: 921-925Crossref PubMed Scopus (19) Google Scholar and some did not clearly distinguish between DES and NE. Also, none of the studies were controlled trials. Given these limitations, the data on surgical myotomy suggest a trend toward symptomatic relief in the subgroup of patients with severe, refractory symptoms.1Kahrilas PJ Esophageal motility disorders: current concepts of pathogenesis and treatment.Can J Gastroenterol. 2000; 14: 221-231PubMed Google Scholar Summary.-Treatment of DES and NE should begin with reassurance and a thorough search for underlying GERD. Antireflux medications should be considered early in the course of disease. Anxiolytics such as trazodone have been shown to help some patients. Endoscopic dilation is of no proven benefit, and surgical myotomy should be cautiously considered in patients with recalcitrant disease, with the understanding that it may not adequately alleviate symptoms and may cause severe adverse effects. Symptoms of esophageal motility disorders include chest pain, dysphagia of liquids and solids, and regurgitation. On first glance it is difficult if not impossible to separate the benign disorders from the serious abnormalities. A thorough history and physical examination, coupled with proper manometric, endoscopic, and radiological evaluations, can readily identify most common esophageal motility disorders. Although not every patient's disorder will correspond to a single diagnosis, the diagnosis can be accurate in most patients. Medical and endoscopic therapies are available. Surgical approaches should be considered only in a small subset of patients with severe and unresponsive illness.