Editing Oesophageal motility disorders (section)

=== '''Diffuse     oesophageal spasm''' ===

** Also known as distal      oesophageal spasm
** Epidemiology
*** Uncommon and poorly       understood
*** More common in women and       those with multiple medical issues
** Presentation
*** Symptoms of chest pain and       dysphagia, often related to eating, mimicking angina
**** Often pronounced during        times of heightened emotional stress
**** Regurgitation of        oesophageal contents and saliva
** Pathophysiology
*** Premature and rapidly       propagated contractions in the distal oesophagus
*** Muscular hypertrophy and       degeneration of the branches of the vagus
** Dx manometry - repetitive,      simultaneous, high amplitude contractions
**
** Medical treatment is      mainstay
*** Start with PPI therapy
*** If no improvement, add       peppermint oil before meals as a smooth muscle relaxant
**** ML says doesn't work, but        can try Fisherman's Friend
*** Then trial antispasmodic       (hyoscyamine) or nitrate
*** Patients with predominant       chest pain symptoms who still don't improve could trial TCA       (amitriptyline 10-25mg nocte, not PRN, for four weeks)
** Surgical: (if refractory to      medical therapy, trial a stepwise intervention approach)
*** Botox
*** Bougie dilatation up to 50       or 60Fr provides relief for severe dysphagia in 70-80% of cases
*** POEM/surgical myotomy
**** Indications for surgery -        incapacitating chest pain or dysphagia who have failed medical therapy.
***** Need to release the         entire length of the abnormal motility
***** Extend down as far as         LOS, but not generally onto the stomach
***** Generally do a Dor         fundoplication at the same time to protect against reflux
***** Reportedly improves         symptoms in 80%
***** POEM has been reported to         have a success rate of 93%