Motilitätsstörungen des Ösophagus – Was ist neu?

Im Extremfall können sich Patienten mit Ösophagus-Motilitätsstörungen nicht ausreichend ernähren – und auch pulmologische Komplikationen kommen vor. Die Achalasie ist die wichtigste definierte Ösophagus-Motilitätsstörung. In den letzten 10–15 Jahren gewann man neue Erkenntnisse zur Pathophysiologie; und neue diagnostische und therapeutische Verfahren ermöglichen nun eine frühere Erkennung und zielgenauere Therapie dieser und anderer Ösophagus-Motilitätsstörungen.

Abstract

Esophageal motor disorders are an important cause of dysphagia but can also be associated with retrosternal pain and heartburn as well as regurgitation. In extreme cases, patients are not able to eat appropriately and lose weight. Repetitive aspiration can occur and may cause pulmonological complications. Achalasia represents the most important and best-defined esophageal motor disorder and is characterized by insufficient relaxation of the lower esophageal sphincter in combination with typical disturbances of esophageal peristalsis. Additional defined motor disorders are distal esophageal spasm, hypercontractile esophagus, absent contractility and ineffective peristalsis. Patients with appropriate symptoms should primarily undergo esophagogastroduodenoscopy for exclusion of e.g., tumors and esophagitis. Esophageal high-resolution manometry is the reference method for diagnosis and characterization of motor disorders in non-obstructive dysphagia. An esophagogram with barium swallow may deliver complementary information or may be used if manometry is not available. Balloon dilatation and Heller myotomy are long established and more or less equally effective therapeutic options for patients with achalasia. Peroral endoscopic myotomy (POEM) enhances the therapeutic armamentarium for achalasia and hypertensive/spastic motor disorders since 2010. For hypotensive motor disorders, which may occur as a complication of e.g., rheumatological diseases or idiopathically, therapeutic options are still limited.

Kernaussagen

• Ösophagus-Motilitätsstörungen sind eine wichtige Ursache dysphagischer Beschwerden, aber auch von retrosternalen Schmerzen oder Brennen sowie Regurgitationen.

• Die Achalasie ist charakterisiert durch eine unzureichende bzw. fehlende schluckinduzierte Erschlaffung des unteren Ösophagus-Sphinkters (UÖS) sowie typische Störungen der tubulären Motilität.

• Der langfristige Gebrauch potenter Opioidanalgetika kann hypertensiv-spastische und achalasieartige Krankheitsbilder verursachen.

• Die hochauflösende Ösophagus-Manometrie ist das Referenzverfahren für die Diagnostik ösophagealer Motilitätsstörungen.

• Die perorale endoskopische Myotomie (POEM) hat das therapeutische Spektrum bei Achalasie wesentlich erweitert und stellt v.a. bei Typ-III-Achalasie das bevorzugte Therapieverfahren dar.

• Die Therapie dysphagischer Beschwerden bei hypotensiven Motilitätsstörungen basiert vor allem auf Allgemein- sowie diätetischen Maßnahmen, mit gutem Kauen, aufrechter Körperhaltung beim Essen und Trinken sowie ggf. breiiger bzw. flüssiger Kost.

• In Deutschland gibt es aktuell keine zugelassenen Prokinetika zur Therapie von Motilitätsstörungen des oberen Gastrointestinaltrakts.

Schlüsselwörter

Motilitätsstörung - Ösophagus - Achalasie - Ösophagusspasmus - hyperkontraktil

Keywords

motility disorder - esophagus - achalasia - esophageal spasm - hypercontractile

Publication History

Article published online:
01 September 2023

• Literatur

• 1 Gockel I, Müller M, Schumacher J. Achalasia--a disease of unknown cause that is often diagnosed too late. Deutsches Arzteblatt international 2012; 109 (12) 209-214 DOI: 10.3238/arztebl.2012.0209. (PMID: 22532812)
• 2 Sakai P, Ishioka S, Pinotti HW. et al. Treatment of megaesophagus with forced dilatation of cardia through hydrostatic balloon attached to a fiberesophagoscope. Endoscopy 1979; 11 (02) 116-120
• 3 Heller E. Extramuköse Cardiaplastik beim chronischen Cardiospasmus mit Dilatation des Oesophagus. Mitt Grenzgeb Med Chir 1913; 27: 141-149
• 4 Kahrilas PJ, Bredenoord AJ, Fox M. et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27 (02) 160-174 DOI: 10.1111/nmo.12477. (PMID: 25469569)
• 5 Yadlapati R, Kahrilas PJ, Fox MR. et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(©). Neurogastroenterol Motil 2021; 33 (01) e14058 DOI: 10.1111/nmo.14058. (PMID: 33373111)
• 6 Keller J, Fox MR, Allescher HD. et al. Interpretation und performance of high-resolution esophageal manometry: Recommendations of the German Association of Neurogastroenterology and Motility (DGNM) and the German Association of Gastroenterology, Digestive and Metabolic Diseases (DGVS). Z Gastroenterol 2018; 56 (11) 1378-1408 DOI: 10.1055/a-0713-0944. (PMID: 30419581)
• 7 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42 (04) 265-271 DOI: 10.1055/s-0029-1244080. (PMID: 20354937)
• 8 Gennaro N, Portale G, Gallo C. et al. Esophageal achalasia in the Veneto region: epidemiology and treatment. Epidemiology and treatment of achalasia. J Gastrointest Surg 2011; 15 (03) 423-428 DOI: 10.1007/s11605-010-1392-7. (PMID: 21116729)
• 9 Booy JD, Takata J, Tomlinson G. et al. The prevalence of autoimmune disease in patients with esophageal achalasia. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus/ISDE 2012; 25 (03) 209-213
• 10 Zendehdel K, Nyren O, Edberg A. et al. Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol 2011; 106 (01) 57-61 DOI: 10.1038/ajg.2010.449. (PMID: 21212754)
• 11 Gaber CE, Eluri S, Cotton CC. et al. Epidemiologic and Economic Burden of Achalasia in the United States. Clin Gastroenterol Hepatol 2022; 20 (02) 342-352 DOI: 10.1016/j.cgh.2021.02.035. (PMID: 33652152)
• 12 Ates F, Vaezi MF. The Pathogenesis and Management of Achalasia: Current Status and Future Directions. Gut and liver 2015; 9 (04) 449-463 DOI: 10.5009/gnl14446. (PMID: 26087861)
• 13 Ghisa M, Laserra G, Marabotto E. et al. Achalasia and Obstructive Motor Disorders Are Not Uncommon in Patients With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2021; 19 (08) 1554-1563
• 14 Chen S, Zhang M, Liang M. et al. The Number of Interstitial Cells of Cajal Differs Among Different Subtypes of Achalasia and is Related to Patients’ Prognosis. Clinical and translational gastroenterology 2021; 12 (08) e00388
• 15 Gockel I, Becker J, Wouters MM. et al. Common variants in the HLA-DQ region confer susceptibility to idiopathic achalasia. Nat Genet 2014; 46 (08) 901-904 DOI: 10.1038/ng.3029. (PMID: 24997987)
• 16 Gaber CE, Cotton CC, Eluri S. et al. Autoimmune and viral risk factors are associated with achalasia: A case-control study. Neurogastroenterol Motil 2022; 34 (07) e14312
• 17 Furuzawa-Carballeda J, Aguilar-Leon D, Gamboa-Dominguez A. et al. Achalasia--An Autoimmune Inflammatory Disease: A Cross-Sectional Study. J Immunol Res 2015; 2015: 729217 DOI: 10.1155/2015/729217. (PMID: 26078981)
• 18 Priego-Ranero Á, Opdenakker G, Uribe-Uribe N. et al. Autoantigen characterization in the lower esophageal sphincter muscle of patients with achalasia. Neurogastroenterol Motil 2022; e14348
• 19 Katzka DA, Farrugia G, Arora AS. Achalasia secondary to neoplasia: a disease with a changing differential diagnosis. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus/ISDE 2012; 25 (04) 331-336
• 20 Geeraerts A, Geysen H, Ballet L. et al. Codeine induces increased resistance at the esophagogastric junction but has no effect on motility and bolus flow in the pharynx and upper esophageal sphincter in healthy volunteers: A randomized, double-blind, placebo-controlled, cross-over trial. Neurogastroenterol Motil 2021; 33 (05) e14041 DOI: 10.1111/nmo.14041. (PMID: 33232555)
• 21 Snyder DL, Vela MF. Opioid-induced esophageal dysfunction. Curr Opin Gastroenterol 2020; 36 (04) 344-350 DOI: 10.1097/MOG.0000000000000648. (PMID: 32427604)
• 22 Patel DA, Goss J, Hayat M. et al. Opioid Exposure Differentially Impacts Esophageal Body Contraction Over the Lower Esophageal Sphincter. Gastroenterology 2022; 163 (02) 403-410 DOI: 10.1053/j.gastro.2022.04.051. (PMID: 35537552)
• 23 Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol 2017; 15 (09) 1338-1349 DOI: 10.1016/j.cgh.2017.05.014. (PMID: 28529168)
• 24 Anderson SH, Yadegarfar G, Arastu MH. et al. The relationship between gastro-oesophageal reflux symptoms and achalasia. Eur J Gastroenterol Hepatol 2006; 18 (04) 369-374
• 25 Vaezi MF, Baker ME, Achkar E. et al. Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment. Gut 2002; 50 (06) 765-770
• 26 Sanagapalli S, Plumb A, Sweis R. Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction. Neurogastroenterol Motil 2022; 34 (03) e14322 DOI: 10.1111/nmo.14322. (PMID: 35072303)
• 27 Bredenoord AJ, Fox M, Kahrilas PJ. et al. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil 2012; 24 (Suppl. 01) 8 DOI: 10.1111/j.1365-2982.2011.01834.x. (PMID: 22248109)
• 28 Tack J, Pauwels A, Roman S. et al. European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus. Neurogastroenterol Motil 2021; 33 (05) e14043 DOI: 10.1111/nmo.14043. (PMID: 33274525)
• 29 Pandolfino JE, Gawron AJ. Achalasia: a systematic review. Jama 2015; 313 (18) 1841-1852 DOI: 10.1001/jama.2015.2996. (PMID: 25965233)
• 30 Carlson DA, Schauer JM, Kou W. et al. FLIP Panometry helps identify clinically relevant esophagogastric junction outflow obstruction per Chicago Classification v4.0. Am J Gastroenterol 2023; 118 (01) 77-86
• 31 Carlson DA, Gyawali CP, Khan A. et al. Classifying Esophageal Motility by FLIP Panometry: A Study of 722 Subjects With Manometry. Am J Gastroenterol 2021; 116 (12) 2357-2366
• 32 Naveiro JJ. Diltiazem in esophageal motility disorders. Acta Gastroenterol Latinoam 1984; 14 (02) 117-125 (PMID: 6535355)
• 33 Triadafilopoulos G, Aaronson M, Sackel S. et al. Medical treatment of esophageal achalasia. Double-blind crossover study with oral nifedipine, verapamil, and placebo. Dig Dis Sci 1991; 36 (03) 260-267
• 34 Tustumi F. Evaluating the Non-conventional Achalasia Treatment Modalities. Front Med (Lausanne) 2022; 9: 941464 DOI: 10.3389/fmed.2022.941464. (PMID: 35814742)
• 35 Oude Nijhuis RAB, Zaninotto G, Roman S. et al. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2020; 8 (01) 13-33
• 36 Boeckxstaens GE, Annese V, des Varannes SB. et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011; 364 (19) 1807-1816 DOI: 10.1056/NEJMoa1010502. (PMID: 21561346)
• 37 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65 (05) 732-739 DOI: 10.1136/gutjnl-2015-310602. (PMID: 26614104)
• 38 Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials. Asian J Surg 2023; 46 (01) 24-34 DOI: 10.1016/j.asjsur.2022.03.116. (PMID: 35484068)
• 39 Shiu SI, Chang CH, Tu YK. et al. The comparisons of different therapeutic modalities for idiopathic achalasia: A systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101 (24) e29441 DOI: 10.1097/MD.0000000000029441. (PMID: 35713453)
• 40 Andolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 2019; 106 (04) 332-341 DOI: 10.1002/bjs.11049. (PMID: 30690706)
• 41 Tan MZ, Whitgift J, Warren H. Mediastinitis, pseudo-aneurysm formation, aortic bleed, and death from endoscopic botulinum toxin injection. Endoscopy 2016; 48 (Suppl. 01) E186-E187 DOI: 10.1055/s-0042-107074. (PMID: 27213973)
• 42 Vespa E, Pellegatta G, Thoguluva Chandrasekar V. et al. Long-Term Outcomes of Per-Oral Endoscopic Myotomy (POEM) for Achalasia: a Systematic Review and Meta-analysis. Endoscopy 2022; 55 (02) 167-175
• 43 Kumbhari V, Tieu AH, Onimaru M. et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3 (03) E195-E201 DOI: 10.1055/s-0034-1391668. (PMID: 26171430)
• 44 Kane ED, Budhraja V, Desilets DJ. et al. Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia. Surgical endoscopy 2019; 33 (03) 886-894 DOI: 10.1007/s00464-018-6356-0. (PMID: 30054739)
• 45 Ponds FA, Fockens P, Lei A. et al. Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. Jama 2019; 322 (02) 134-144
• 46 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med 2019; 381 (23) 2219-2229 DOI: 10.1056/NEJMoa1905380. (PMID: 31800987)
• 47 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87 (04) 934-943
• 48 Zagari RM, Marasco G, Tassi V. et al. Risk of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus in Patients With Achalasia: A Long-Term Prospective Cohort Study in Italy. Am J Gastroenterol 2021; 116 (02) 289-295
• 49 Ota M, Narumiya K, Kudo K. et al. Incidence of Esophageal Carcinomas After Surgery for Achalasia: Usefulness of Long-Term and Periodic Follow-up. Am J Case Rep 2016; 17: 845-849 DOI: 10.12659/ajcr.899800. (PMID: 27840406)
• 50 Pimentel M, Bonorris GG, Chow EJ. et al. Peppermint oil improves the manometric findings in diffuse esophageal spasm. J Clin Gastroenterol 2001; 33 (01) 27-31 DOI: 10.1097/00004836-200107000-00007. (PMID: 11418786)
• 51 Khalaf MHG, Chowdhary S, Elmunzer BJ. et al. Impact of Peppermint Therapy on Dysphagia and Non-cardiac Chest Pain: A Pilot Study. Dig Dis Sci 2019; 64 (08) 2214-2218 DOI: 10.1007/s10620-019-05523-8. (PMID: 30771044)
• 52 Vanuytsel T, Bisschops R, Farre R. et al. Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders. Clin Gastroenterol Hepatol 2013; 11 (09) 1115-1121
• 53 Albers D, Frieling T, Dakkak D. et al. Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study. Z Gastroenterol 2018; 56 (11) 1337-1342 DOI: 10.1055/a-0668-2605. (PMID: 30296811)
• 54 de Bortoli N, Gyawali PC, Roman S. et al. Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116 (02) 263-273
• 55 Wang D, Wang X, Yu Y. et al. Assessment of Esophageal Motor Disorders Using High-resolution Manometry in Esophageal Dysphagia With Normal Endoscopy. J Neurogastroenterol Motil 2019; 25 (01) 61-67
• 56 Kessing BF, Smout AJ, Bennink RJ. et al. Prucalopride decreases esophageal acid exposure and accelerates gastric emptying in healthy subjects. Neurogastroenterol Motil 2014; 26 (08) 1079-1086 DOI: 10.1111/nmo.12359. (PMID: 24891067)
• 57 Lei WY, Hung JS, Liu TT. et al. Influence of prucalopride on esophageal secondary peristalsis in reflux patients with ineffective motility. J Gastroenterol Hepatol 2018; 33 (03) 650-655
• 58 Jandee S, Geeraerts A, Geysen H. et al. Management of Ineffective Esophageal Hypomotility. Front Pharmacol 2021; 12: 638915 DOI: 10.3389/fphar.2021.638915. (PMID: 34122066)