This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. So how do we move forwards in this obstructed esophagus realm? With compatible symptoms, initial tests, you rule out mechanical obstruction, you do a manometry, you have the three achalasia subtypes. There are a few caveats. Short history, weight loss, think pseudo-achalasia. Opiates, think opioid-induced motor dysmotility. Absent contractility with significant dysphagia. Think type 1 achalasia, even if the IRP is normal. Do additional tests to rule that out. And motor EGJ outflow obstruction. Confirmed conclusive motor EGJ outflow obstruction. So no mechanical etiology. An alternative test abnormal. That tells you something is going on. How do we treat this? Well, we try to destroy the obstructive motor element there. Whether that's the LES, where you can do pneumatic dilation or hell or myotomy, or the entire esophagus, where POM, a tailored POM, is probably going to provide the better option. In patients who are poor surgical risks, you may have to think about other options like Botox. Sildenafil doesn't work very well, but can be tried. And in end-stage achalasia, you take the esophagus out or you feed the patient distal to the esophagus. Similar treatment options may be reasonable. In confirmed motor EGJ outflow obstruction. So if you go to the Chicago classification, these alternate tests, these adjunctive tests, barium and FLIP, will bring EGJ outflow obstruction, if abnormal, to the realm of disorders of EGJ function. And if that's negative, then you have no EGJ outflow obstruction, even if the IRP is abnormal in the context of intact esophageal body peristalsis. Now, if you have ruled out obstruction, then you go into the disorders of esophageal body abnormality. So absent contractility, distal esophageal spasm, there are lots of premature sequences, hypercontractile esophagus, and finally, ineffective esophageal motility. These terms have to be used with caution, because they have to be clinically relevant to make sense. The one that is least relatable to patient symptoms is ineffective esophageal motility, and it really pains me when patients come to me and tell me, I have IEM. What symptom do you have? Not really anything other than reflux. Well, treat the reflux, not the IEM. The situations where the esophagus needs to be treated with motor disorders is obstructive motor disorders. The remainder probably don't need the esophagus intervened upon, but the patient's symptoms treated. Now, even in these disorders of esophageal peristalsis, if the symptom is significant dysphagia, you still need to look for obstruction. You may still need to do these adjunctive tests.

diagnose and treat obstructed esophagus conditions

mechanical obstruction

achalasia subtype

pseudo-achalasia

opiate-induced motor dysmotility