Esophageal Motility and Esophagitis

Motility Disorders and Esophagitis are must-know esophageal pathologies are NOT inherently malignant (cancerous), but may be associated with increased risk for malignancy.



Motility Disorders

  • Achalasia – failure of the lower esophageal sphincter (LES) to relax.
    • Pathophysiology:  ganglion cell and myenteric plexus breakdown, cholinergic nerve predominance leading to persistent contraction of muscle.
    • Cancer risk:  squamous cell esophageal cancer in those with >10 year history of achalasia.
    • Clinically:  dysphagia to solids and liquids, regurgitation of bland food; chest pain, weight loss.  No response to PPI.
    • Best initial test:  barium esophagogram (bird’s beak appearance!)
    • Confirmatory test:  manometry
    • EGD may be done to ensure there is no mass obstruction or concomitant pathology (e.g. ulcer, inflammation)
      • Mimicking condition:  malignant/benign tumors that invade nearby esophageal nerves (pseudoachalasia).
        • Consider when patient c/o weight loss and age > 60
    • Treatment:
      • Pneumatic dilation via upper endoscopy (slightly cheaper)
      • Surgical myotomy
      • Both aforementioned treatments have similar rates of success!
      • Injection of botulinum toxin via EGD has 50% relapse rate at/before 6 months.
      • Last line:  CCBs (nifedipine) or prolonged-release nitrates.
  • Diffuse Esophageal Spasm / Nutcracker Esophagus
    • Clinically:  chest pain similar to angina and dysphagia.
    • Pathophysiology:  unknown; concomitant high-amplitude (>30 mm Hg in DES; >220 mmHg in Nutcracker) esophageal muscular contractions.
    • Diagnosis:  barium esophagogram “corkscrew esophagus
    • Treatment:  CCBs, botulinum toxin, hydralazine, and/or anxiolytics.


  • Infectious Esophagitis – bacterial, fungal, parasitic, viral.
    • Clinically:  painful swallowing and/or dysphagia.
    • Candida (albicans) – both immunocompetent and immunocompromised patients
      • EGD will show small white raised plaques.
      • Treatment:  Fluconazole PO
    • CMV – immunocompromised patients only.
      • EGD with biopsy of ulcer base (CMV base)
      • Treatment:  Ganciclovir and valganciclovir
    • HSV – both immunocompetent and immunocompromised patients
      • EGD with biopsy of ulcer edge (HSV edge)
      • Treatment:  Acyclovir
  • Pill Esophagitis
    • Direct mucosal irritation and inflammation
    • Risk factors:  non-peristalsis of esophagus, medications decreasing muscular function (e.g. opioids), diminished salivary output, direct pill damage.
    • Clinically:  dysphagia, odynophagia, chest pain – can occur a few hours after ingestion or days later.
    • Typical offenders:
      • Alendronate, ferrous sulfate, mexiletine, tetracycline, doxycycline, quinidine, potassium.
    • Worry about stricture progression with:
      • Alendronate, NSAIDs, potassium, ferrous sulfate.
    • Prevention is key!  Simply drink plenty of water/fluids when taking pill and sit UP greater than/equal to 30 minutes.
  • Eosinophilic Esophagitis
    • Squamous mucosal inflammation secondary to permeation of eosinophils.
    • Think of when seeing:  atopic man, near middle age, with dysphagia to solid foods and frequent food blockages.
    • Associated with asthma, eczema, food allergies.
    • Population studies:  54 per 100,000 people in the US.
    • Diagnosis:  EGD shows longitudinal furrows, stenosis of lumen, leukoplakia and white exudates, and rings.  BIOPSY shows eosinophils, >15 eos per HPF.
    • Must rule out GERD-induced esophageal eosinophilia via trial of PPI.
      • If repeat biopsy shows improvement post-PPI, you’ve diagnosed GERD-associated eosinophilia.
      • If no improvement with PPI, it is eosinophilic esophagitis!
    • Treatment:
      • Diet modification (stop eating foods that agitate esophagus)
      • Swallowed aerosolized glucocorticoids – budesonide or fluticasone
      • Oral prednisone (if above don’t work)
      • Treat any associated strictures with dilation.
      • CHRONIC process with high recurrence rate if treatment interruption.


  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 3-7
  • Image source:

1 thought on “Esophageal Motility and Esophagitis”

  1. Thank you for pointing out that esophageal diseases like motility disorders and esophagitis are important to understand because they may be linked to higher risks for cancer. It’s always interesting to learn something new about health concerns like this so thank you. This, however, made me wonder about Esophageal Manometry Training and how important it is for patients that need help.

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