Review articleTreatment of spastic esophageal motility disorders
Section snippets
Problems with therapeutic trials in patients with spastic motility
Despite the frequently noted prevalence of these disorders, their cause, pathophysiology, and importance remains to be determined [3]. The structural basis of the abnormal esophageal motility patterns has been difficult to study because most of these patients do not require surgery or rarely, if ever, come to autopsy. It is unclear whether the manometric abnormalities in patients with NCCP have physiologic consequences. During manometry, patients noted to have simultaneous contractions
Pharmacologic treatment
Traditionally, pharmacologic options for painful motility disorders have been directed at reducing or improving the abnormal esophageal pressures or uncoordinated motility. The pharmacologic agents used for this purpose include nitrates, calcium antagonists (such as nifedipine or diltiazem), and anticholinergic compounds [8]. Long-term outcome studies are unavailable, and most of the basis for therapy in this area remains anecdotal [9]. In addition to the agents mentioned previously, we
Tricyclic antidepressants
Psychiatric illness has been reported in as many as 84% of cases of patients with chest pain and esophageal dysmotility [55]. Investigators have found a higher prevalence of psychiatric diagnoses among patients with NEMD when compared with patients having achalasia or normal manometry. The most common psychiatric diagnoses identified among these patients include anxiety disorders, depression, somatization, and perceived vulnerability to serious heart disease and panic disorders [55], [56], [57]
Selective serotonin reuptake inhibitors
The results of the previously described trials with imipramine and trazodone raise the possibility that other psychotropic agents may be effective for the treatment of patients suffering from recurrent chest pain. This is important because the traditionally available agents imipramine and trazodone can produce undesirable effects, such as anticholinergic reactions, antiarrhythmic activity, and sedating effects, which limit their use. Furthermore, trazodone can induce priapism. Imipramine has
Enhanced visceral pain perception
The studies described above have shown a discordant outcome between the changes in esophageal motility and therapeutic outcome and thus have raised the possibility that mechanisms other than disturbed motility may contribute to the patients' symptoms. Several investigators have observed an increased pain perception (nociception or visceral hyperalgesia) in patients with chest pain after a variety of stimuli [71], [72], [73], [74], [75]. Schapiro et al [71] reproduced chest pain by intra-atrial
Pharmacologic treatment for visceral perception
The finding of visceral hyperalgesia in patients with NCCP has shifted therapeutic efforts to seek agents that can blunt visceral sensation. Beause visceral hyperalgesia is an abnormality shared by patients with other functional GI disorders, it is possible that drugs capable of producing a beneficial effect for patients with IBS might offer the same salutatory effects for those with NCCP.
Summary
Treatment of spastic motility disorders continues to be challenging. Therapeutic options remain limited due in part to our lack of understanding of the pathophysiology and significance of these disorders. Furthermore, most of therapeutic trials to date are hampered by the poorly designed nature of the study, including the small size of the trials and the lack of placebo arm. Most of the available information suggests that there seems to be an important dissociation between symptoms (chest
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