Minor disorders of peristalsis
Many patients referred for investigation of symptoms such as dysphagia or chest pain have abnormal manometric features that do not meet the criteria for achalasia, distal oesophageal spasm, or hypercontractile oesophagus. Cases where peristaltic waves are of abnormally low amplitude in the distal oesophagus are categorized as ineffective oesophageal motility, while patients who exhibit large breaks in the peristaltic sequence are diagnosed with fragmented peristalsis.37 These ‘minor disorders’ of oesophageal motor function are evident in more than one‐third of presentations with dysphagia in patients over age 65, in contrast to the young, where a specific diagnosis can usually be made. It is important to recognise that a causal association cannot be assumed since the presence of radiographic or manometric abnormalities of oesophageal function correlates poorly with symptoms. Moreover, no specific therapy is available. Symptomatic management includes acid suppression when GORD is a feature and optimising nutrition.
‘Pill esophagitis’
An important cause of dysphagia or odynophagia in older individuals is mucosal injury caused by impaction of medications in the oesophagus, the incidence of which is likely to increase as the number of medications prescribed in this group escalates. Risk factors that are more prevalent in the elderly include less saliva, delayed oesophageal transit, and immobility (particularly recumbent position). Capsules – especially if gelatin‐coated – may present a greater risk than tablets due to slower oesophageal transit, and extended‐ or sustained‐release formulations are often implicated. The most frequent sites of hold‐up are the upper and mid‐oesophagus, corresponding to extrinsic compression from the left main bronchus, aortic arch, or enlarged left atrium, and also to a zone of low‐amplitude pressure waves between the proximal and distal oesophagus. Numerous medications are associated with oesophageal injury, including potassium chloride, tetracyclines, aspirin, non‐steroidal drugs, quinidine, theophylline, ferrous sulfate, and alendronate.38 Dabigatran has also recently been associated with extensive sloughing of the oesophageal mucosa.39
Figure 17.3 Oesophageal manometry in achalasia (type 2), displayed as a pressure topography plot. Note the simultaneous low‐amplitude pressure waves in the oesophageal body, i.e. pan‐oesophageal pressurization, and failure of LOS relaxation on swallowing.
Figure 17.4 Manometry recording in distal oesophageal spasm, displayed as a pressure topography plot. Note the excessively rapid propagation of contractions along the oesophagus (premature contractions) as well as a hypercontractile response in the distal oesophagus.
Symptoms usually resolve when the offending drug is withdrawn but may be persistent and related to stricture formation. Perforation and bleeding are other associated complications, particularly with potassium chloride, quinidine, and non‐steroidal drugs. The typical endoscopic or barium swallow appearance in pill esophagitis is of small superficial ulcers. There is anecdotal evidence that sucralfate is beneficial in severe or persistent disease. As a preventive measure, patients should be advised to take oral medications in the upright position, followed immediately by a full glass of water.
Figure 17.5 Barium swallow in a patient with distal oesophageal spasm, demonstrating segmentation of the barium column by contractions, producing a corkscrew appearance.
Non‐cardiac chest pain
Chest pain is a prevalent symptom in the community and not infrequently presents diagnostic difficulty, especially in older patients who are at greater risk of ischaemic heart disease than the young. The oesophagus is often implicated when cardiac causes have been excluded, but musculoskeletal, pulmonary, pericardial, gastric, and biliary pathology should also be considered, and an association with panic disorder has been reported.40
GORD may be responsible for a proportion of non‐cardiac chest pain (NCCP), and about 50% of NCCP patients have excessive oesophageal acid exposure on pH studies. Many patients with excessive acid exposure do not have reflux esophagitis, limiting the value of endoscopic examination. Rather, a trial of a double‐dose proton pump inhibitor (PPI) for between two and eight weeks (depending on symptom frequency) is a useful and cost‐effective initial test in NCCP, with a sensitivity and specificity as high as 80% for a diagnosis of GORD. If symptoms are relieved, the medication dose can subsequently be titrated down to the minimum effective dose. If PPIs prove ineffective, oesophageal manometry and ambulatory pH measurement (while remaining on the PPI) are indicated; the former is particularly helpful for excluding achalasia. Endoscopy should be performed whenever there are ‘alarm symptoms’ such as dysphagia, anorexia, weight loss, hematemesis, or anaemia. The threshold for endoscopy in older patients should be lower than that in the young (age less than 40).
The association between NCCP and oesophageal motility disorders, including distal oesophageal spasm and jackhammer oesophagus, is less strong than previously assumed, and even when these disorders are demonstrated, a causal relationship can be difficult to establish. Furthermore, medical therapy for oesophageal motility disorders with smooth muscle relaxants such as nitrates, calcium channel antagonists, or sildenafil has limited efficacy. Botulinum toxin injection, surgical myotomy, and POEM have been advocated but currently do not have strong evidence to support their use.41
Visceral hypersensitivity is now considered to play a major role in non‐GORD related NCCP, and pain‐modifying agents, including tricyclic antidepressants and selective serotonin reuptake inhibitors, have been shown to be superior to placebo in the management of this disorder. Limited data also suggest that theophylline, an adenosine receptor antagonist, may be beneficial. Caution should be exercised in the elderly due to potential adverse effects of all these agents, particularly tricyclics. Psychological techniques, such as cognitive behavioural therapy, are reported to have good outcomes in NCCP, as is the case with other functional gastrointestinal disorders.
It is generally assumed that NCCP, although often persistent over a number of years, has an excellent prognosis in terms of mortality, although this remains controversial42 and may depend on the specific population being considered.
Gastro‐oesophageal reflux disease
GORD is the sixth most common disorder amongst the elderly in residential care, which is not surprising; even in the general population, around 20% experience weekly reflux symptoms.43 GORD presents in the elderly with more severe mucosal injury (erosive esophagitis, stricture, or Barrett’s oesophagus) than in the young, yet symptoms are characteristically milder or may be qualitatively different. Thus dysphagia, vomiting, respiratory difficulty, weight loss, and anaemia are not uncommon presenting features, while ‘typical’ reflux symptoms like heartburn occur less often than in the young, reflecting diminished oesophageal sensitivity. In the general population, symptoms of heartburn or regurgitation have a high sensitivity (about 70%) for a diagnosis of GORD but low specificity when
