Classification of oesophageal motility abnormalities

Abstract

Manometric examination of the oesophagus frequently reveals abnormalities whose cause is unknown and whose physiological importance is not clear. A large body of literature dealing with oesophageal motility abnormalities has evolved over the past few decades but comparisons among studies have been compromised by the lack of a widely accepted system for classifying the abnormal motility patterns, and by the lack of uniform diagnostic criteria for the putative disorders. Based on an extensive review and analysis of the literature, this report suggests an operational scheme to be used for the general classification of oesophageal motility abnormalities, and proposes standardised manometric criteria for the putative oesophageal motility disorders. By applying the guidelines proposed in this report, clinicians and researchers can determine if their patients fulfil the manometric criteria for a putative motility disorder. This should facilitate and improve comparisons among patients and studies. However, it is important to emphasise that fulfilment of the proposed criteria does not establish the clinical importance of the motility abnormalities.

Figures

Figure 1

(A) Oesophageal manometry tracing from a patient with classic achalasia. The distal recording site, positioned in the lower oesophageal sphincter (LOS), shows high basal LOS pressure (approximately 60 mm Hg). Note that the two wet swallows (WS) are followed by incomplete relaxation of the LOS with residual pressure values of 24 and 36 mm Hg. The two proximal recording sites, located 3 and 8 cm above the LOS, show that wet swallows are not attended by peristalsis. (B) Oesophageal manometry tracing from a patient with classic achalasia. The three recording sites are positioned 3, 8, and 13 cm above the LOS. Note that wet swallows (WS) are not followed by peristaltic contractions, and that the pressure changes recorded in the oesophageal body are simultaneous, low amplitude, and identical in appearance (isobaric).

Figure 2

Oesophageal manometry tracing from a patient with diffuse oesophageal spasm. The recording sites are positioned 3, 8, and 13 cm above the lower oesophageal sphincter. Note that the first wet swallow (WS) is followed by oesophageal contractions that are simultaneous and repetitive. However, some peristaltic activity is preserved, as evidenced by the peristaltic contraction of the oesophageal body shown in the sequence on the right.

Figure 3

Oesophageal manometry tracing from a patient with nutcracker oesophagus. The recording sites are positioned 3, 8, and 13 cm above the lower oesophageal sphincter. Note the high amplitude peristaltic contractions initiated by wet swallows (WS).

Figure 4

Oesophageal manometry tracing from a patient with ineffective oesophageal motility. The recording sites are positioned 3, 8, and 13 cm above the lower oesophageal sphincter. Note that the first and third wet swallows (WS) result in normal peristaltic sequences. However, the second wet swallow stimulates only low amplitude contractions in the proximal two leads, and no contraction in the distal lead (non-transmitted contraction or "failed peristalsis").