Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium

Nicola de Bortoli, Prakash Chandra Gyawali, Sabine Roman, Salvatore Tolone, Daniel Sifrim, Radu Tutuian, Roberto Penagini, John Erik Pandolfino, Edoardo Vincenzo Savarino

Research output: Contribution to journalReview articlepeer-review

Abstract

Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.

Original languageEnglish
Pages (from-to)263-273
Number of pages11
JournalThe American journal of gastroenterology
Volume116
Issue number2
DOIs
Publication statusPublished - Feb 1 2021

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

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