Overview

Oesophageal dysmotility is a condition that affects your oesophagus, which is the muscular tube that carries food and drink from your mouth to your stomach. When you swallow, the muscles in your oesophagus normally contract in a coordinated way, pushing food downwards. In oesophageal dysmotility, these muscle contractions don't work as they should. They might be irregular, unsynchronised, or even completely absent, making it difficult for food and liquid to move smoothly into your stomach.

This difficulty with swallowing, known as dysphagia, is a common symptom of oesophageal dysmotility. It often feels like food is getting stuck in your throat or chest. One specific type of oesophageal dysmotility is called oesophageal spasm, where the muscles in your food pipe suddenly clench abnormally, preventing food from passing. Another, more specific and rare disorder, is achalasia. With achalasia, the muscles in your oesophagus don't contract properly, and the lower oesophageal sphincter (a ring of muscle at the bottom of your food pipe that acts like a valve) fails to relax and open, meaning food and drink struggle to enter your stomach.

Oesophageal dysmotility can affect anyone, but it is particularly common in older adults. As we age, the muscles and nerves in the digestive tract can become less efficient, which can slow down how food and liquid move through the oesophagus. Sometimes, the sensation of food sticking can be felt higher up in the throat than where the actual problem is located, which is known as a 'referred sensation'. Understanding exactly what is causing your swallowing difficulties is a crucial first step towards finding the right management and treatment.

Symptoms and Causes

Understanding the symptoms and potential causes of oesophageal dysmotility is key to recognising the condition and seeking appropriate medical advice. The symptoms can vary in how severe they are and how often they occur, and they often develop gradually over time, especially in conditions like achalasia.

Symptoms

The main symptom of oesophageal dysmotility is difficulty swallowing, or dysphagia. This can feel like food or drink is getting stuck in your oesophagus as it tries to pass down. Other common symptoms include:

• A 'sticking' sensation: You might feel as though food is getting caught in your throat or chest when you eat or drink.
• Discomfort: This can range from a mild feeling of pressure to more significant chest pain.
• Coughing and choking: Food or liquid might go down the 'wrong way', leading to coughing or a choking sensation.
• Regurgitation: This is when undigested food or liquid comes back up into your mouth, often without warning.
• Heartburn and acid reflux: You might experience a burning sensation in your chest or a sour taste in your mouth, caused by stomach acid flowing back up into your oesophagus.
• Bad breath: This can occur if food gets trapped in the oesophagus and starts to ferment.
• Persistent cough: A cough that doesn't go away can be a sign of irritation from reflux or food particles.
• Frequent or recurrent chest infections: If food or liquid is regularly inhaled into the lungs (aspiration), it can lead to repeated chest infections.
• Weight loss: Significant and unintentional weight loss can occur if you are consistently struggling to eat enough due to swallowing difficulties.
• Drooling: In some cases, difficulty swallowing saliva can lead to drooling.

Causes

Oesophageal dysmotility happens when the normal, coordinated muscle contractions of your oesophagus are disrupted. The specific reasons for this can vary:

• Irregular muscle contractions: In general oesophageal dysmotility, the muscles in your food pipe may contract in an irregular, unsynchronised, or even absent manner. This prevents food from being pushed down smoothly.
• Oesophageal spasm: This involves sudden, abnormal clenching of the oesophageal muscles, which can block the passage of food.
• Achalasia: This is a specific disorder where the oesophageal muscles do not contract correctly, and the lower oesophageal sphincter (the valve at the bottom of your food pipe) fails to open properly. The exact cause of achalasia is not fully known, but it is thought to involve damage to the nerves in the oesophagus. This damage might be linked to viral infections, autoimmune conditions (where your body's immune system mistakenly attacks its own tissues), and very rarely, a faulty gene.
• Age-related changes: In older adults, the muscles and nerves of the digestive tract can naturally become less efficient, which can slow down the movement of food and liquid through the oesophagus.

It's important to note that while this leaflet focuses on oesophageal dysmotility, other physical issues can also cause a sensation of food sticking. These include cervical osteophytes (small bony growths on the bones of your neck), oesophageal strictures (narrowing of the food pipe), and cricopharyngeal dysfunction (a problem where the muscle at the very top of your food pipe doesn't relax properly). Non-physical factors such as cervical spondylitis (a type of arthritis affecting the neck), stress, and anxiety can also contribute to altered sensations in the throat. Your doctor will consider all these possibilities to understand the true cause of your symptoms.

Diagnosis and Investigations

If you are experiencing symptoms of oesophageal dysmotility, your GP will likely refer you to a specialist, often in a hospital setting, for a thorough assessment. The goal is to accurately identify the underlying cause of your swallowing difficulties, as this is crucial for effective management and treatment.

Diagnosis

The diagnostic process typically begins with a detailed discussion about your symptoms, including when they started, how often they occur, what makes them better or worse, and any other health conditions you have. This is known as taking a clinical history. Your doctor will also perform a physical examination. Based on this initial assessment, they will decide which investigations are most appropriate to confirm a diagnosis and rule out other conditions that might cause similar symptoms.

Investigations

Several specialised tests are used to investigate oesophageal dysmotility and related conditions:

• Oesophageal Motility Testing: This is a key investigation that assesses how well your oesophagus is moving food and liquid. It also checks the function of the sphincters (valves) at the top and bottom of your oesophagus.
• • High-Resolution Manometry (HRM): This is the most advanced and detailed type of oesophageal motility testing. It involves passing a thin, flexible tube through your nose into your oesophagus. This tube has many sensors that measure the pressure and coordination of muscle contractions as you swallow small amounts of water. HRM is highly recommended for investigating dysphagia and is particularly effective at characterising specific conditions like achalasia. Sometimes, additional testing with larger volumes of liquid is performed during HRM to get a more complete picture. The results of HRM are often interpreted using a standardised system called the 'Chicago Classification Version 4.0', which helps doctors accurately categorise different oesophageal motility disorders.
  • Before undergoing manometry, you will usually have an endoscopy and biopsies to rule out any structural problems or changes to the lining of your oesophagus.
• pH Studies and pH/Impedance Monitoring: These tests are used to detect acid reflux and non-acid reflux.
• • A thin tube is passed through your nose into your oesophagus, where it stays for 24 hours. It measures the amount of acid and other contents that reflux (flow back) from your stomach into your oesophagus.
  • This monitoring is particularly recommended if you have reflux symptoms that haven't responded to medications like proton pump inhibitors (which reduce stomach acid), or if surgery is being considered.
• Endoscopy: This procedure involves a doctor inserting a thin, flexible tube with a camera (an endoscope) down your throat to visually examine the lining of your oesophagus, stomach, and the first part of your small intestine. This helps to rule out any structural problems, narrowing (strictures), inflammation, or other issues that might be causing your symptoms. Small tissue samples (biopsies) can be taken during an endoscopy for further examination.

For any oesophageal manometry or ambulatory pH monitoring, you will be asked to provide written informed consent. These tests are performed by clinicians who are registered with professional bodies to ensure high standards of care and consistency in practice.

Management and Treatment

Managing oesophageal dysmotility often involves a combination of lifestyle adjustments, dietary changes, and sometimes medication or specific procedures, depending on the underlying cause and severity of your symptoms. The aim is to ease your swallowing difficulties, prevent complications, and improve your quality of life.

Dietary Modifications: Adapting what and how you eat can significantly help manage symptoms:

• Choose soft, moist foods: Naturally soft foods are easier to swallow. Adding sauces, gravies, or extra moisture to your meals can make them smoother.
• Mash or puree foods: For more severe difficulties, mashing or pureeing your food can help it pass more easily through the oesophagus.
• Avoid certain foods: Try to avoid foods that are tough, chewy, or dry, such as sandwiches, salads, or potatoes without sauce. Acidic foods might also worsen discomfort if you have reflux.
• Nutritional fortification: To prevent malnutrition and unintentional weight loss, it's important to maintain your nutritional intake. You can fortify your meals with high-calorie and high-protein additions without increasing portion sizes. Examples include adding cream, condensed milk, or skimmed milk powder to soups, drinks, or other dishes.

Eating Strategies: How you eat is just as important as what you eat:

• Eat slowly: Take your time with meals, allowing plenty of time for each mouthful to pass.
• Take extra swallows: Between mouthfuls of food, take an extra swallow of saliva to help clear your oesophagus.
• Maintain an upright posture: Sit upright during and for at least 30 minutes after eating and drinking. This uses gravity to help food move down and can reduce reflux.

Medication:

• For heartburn and acid reflux: If you experience heartburn or acid reflux, you should consult your GP. They may prescribe medications to reduce stomach acid, which can help manage these symptoms.
• For Achalasia: For specific conditions like achalasia, medications such as nitrates or nifedipine may be prescribed. These work by relaxing the oesophageal muscles, offering temporary relief from symptoms. However, they can have side effects, such as headaches.

Procedures and Surgery (primarily for Achalasia):

• Balloon Dilation: This procedure involves inserting a balloon into the lower oesophageal sphincter and inflating it to stretch the muscle, helping it to open more easily.
• Surgery: More permanent treatments for achalasia include surgical procedures like Heller myotomy or Peroral Endoscopic Myotomy (POEM). These operations involve carefully cutting the muscle fibres of the lower oesophageal sphincter to allow food and drink to pass into the stomach more freely.

It's important to note that the dietary guidance provided here is generally for oesophageal dysmotility. If you have oesophageal narrowing or a blockage, you might require a specific liquidised diet, and this general advice may not be suitable. Always follow the specific advice given by your healthcare team.

Prevention

While the underlying causes of some oesophageal dysmotility conditions, such as achalasia, are not fully understood and therefore cannot be entirely prevented, there are significant steps you can take to prevent the worsening of symptoms and avoid complications. The management strategies discussed earlier are highly effective preventative measures against the impact of the condition on your daily life and health.

• Preventing symptom flare-ups: By consistently following the recommended dietary modifications and eating strategies, you can significantly reduce the frequency and severity of your swallowing difficulties, discomfort, and regurgitation. Choosing naturally soft, moist foods, eating slowly, and remaining upright during and after meals are key habits that help prevent food from getting stuck and reduce the likelihood of reflux.
• Preventing malnutrition and weight loss: Actively fortifying your food with high-calorie and high-protein additions (like cream, condensed milk, or skimmed milk powder) is a crucial preventative measure against unintentional weight loss and malnutrition, which can be serious complications of chronic swallowing difficulties.
• Preventing chest infections: By carefully managing your swallowing and reducing regurgitation, you can lower the risk of food or liquid entering your airways and lungs, thereby preventing recurrent chest infections.
• Managing acid reflux: If you experience heartburn or acid reflux, consulting your GP for potential medication can prevent long-term irritation and damage to the oesophagus that can sometimes be associated with persistent reflux.

These proactive steps are designed to mitigate the symptoms of oesophageal dysmotility, improve your comfort, and maintain your overall health and quality of life. Regular follow-up with your healthcare team will also help to monitor your condition and adjust your management plan as needed, further preventing potential issues.

Outlook / Prognosis

The long-term outlook for individuals with oesophageal dysmotility varies depending on the specific type of condition, its severity, and how well it responds to management and treatment. For many, symptoms can be significantly improved with appropriate strategies, allowing for a good quality of life.

Conditions like achalasia, for example, often develop gradually over many years. While there isn't a cure for the underlying nerve damage in achalasia, treatments like balloon dilation or surgery (Heller myotomy or POEM) are very effective at improving the ability to swallow by addressing the muscle's failure to relax. After these treatments, it's possible to experience side effects such as acid reflux, heartburn, or chest pain. These are often managed successfully with prescribed medication, which helps to control symptoms and prevent complications.

For other forms of oesophageal dysmotility, dietary and eating modifications, along with careful monitoring, can often provide substantial relief. The goal of all management approaches is to make eating and drinking easier and more comfortable, reduce the risk of complications like weight loss or chest infections, and ultimately enhance your overall well-being.

It is important to understand that living with oesophageal dysmotility often involves ongoing management. You may need to continue with dietary adjustments and eating strategies long-term. If you experience persistent swallowing difficulties or continued weight loss even after treatment, it is crucial to seek further medical review. Your healthcare team will monitor your condition and adjust your treatment plan as necessary to ensure the best possible long-term outcome. With a clear understanding of your condition and adherence to your personalised management plan, most people with oesophageal dysmotility can effectively manage their symptoms and lead fulfilling lives.