Esophageal Motility Disorders

Over the past decade, significant advances have been made in the diagnosis and management of esophageal motility disorders. The advent of high-resolution esophageal manometry has allowed greater specificity in diagnosis and recognition of clinically relevant phenotypes, particularly achalasia. New diagnostic modalities including impedance and the Functional Lumen Imaging Probe have provided insight into pathophysiology and further defined disease states. Therapeutic options for achalasia continue to evolve and new seminal trials have helped clarify the pros and cons of definitive achalasia therapy, including pneumatic dilatation, Heller myotomy, and peroral endoscopic myotomy. Peroral endoscopic myotomy has gone from conception to worldwide implementation in the span of a decade and provides comparable outcomes to surgical myotomy. Emerging technology has helped define non-achalasia esophageal motility disorders, including esophagogastric junction outflow obstruction, distal esophageal spasm, and the hypercontractile esophagus. These entities are distinct from achalasia, with less defined natural history and treatment algorithms, but appear to be associated with esophageal symptoms and respond to therapy directed at underlying pathogenesis. Finally, technical advances in endoscopy have resulted in increased diagnostic and therapeutic possibilities through accessibility to the submucosal space. This chapter will summarize the diagnostic and therapeutic options for esophageal motility disorders, focusing on those with endoscopic relevance.