Introduction
Nonspecific esophageal disorder (NEMD) describes esophageal conditions that do not fit with any well-established esophageal motility disorders. NEMDs have been identified in fifty percent of adults with non-cardiac chest pain or dysphagia.
What Is Nonspecific Esophageal Disorder?
Nonspecific esophageal disorder (NEMD) describes esophageal conditions that do not fit with any well-established esophageal motility disorders. NEMDs have been identified in fifty percent of adults with non-cardiac chest pain or dysphagia. It is a broad term for patients with poorly defined esophageal contraction abnormalities. Motility disorders are an important cause of esophageal complaints.
What Are the Signs and Symptoms of a Nonspecific Esophageal Disorder?
Patients can be asymptomatic. At times, some patients present with dysphagia (difficulty in swallowing). An infrequent presenting symptom is chest pain. Commonly seen symptoms include:
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Pain while swallowing.
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Difficulty swallowing.
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Swallowed food gets stuck in the esophagus (food impaction).
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Chest pain that occurs while eating.
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Acid regurgitation.
Small children, particularly infants, who cannot communicate their difficulties properly might present with irritability, arching of their back, and refusal to eat food.
How Is Nonspecific Esophageal Disorder Diagnosed?
1. Case History - A detailed case history would reveal how long this complaint had been present and the various symptoms the patients experienced.
2. Esophagogram (Barium Swallow, Fluoroscopy) - This imaging technique is used to view the upper gastrointestinal tract. It uses a special kind of X-ray called fluoroscopy. The person undergoing this procedure is made to drink a chalky fluid containing barium. The presence of barium in the blood enables us to see the internal organs more clearly. The fluoroscopic examination might reveal interrupted primary peristalsis (peristalsis is the coordinated movement of the esophagus that is initiated by the swallowing of food), variation in the number and severity of tertiary contractions (tertiary peristalsis or tertiary contractions are the contractions that co-occur at different levels of the esophagus), and failure of the lower esophageal sphincter to relax. The radiographic findings in nonspecific esophageal disorders might overlap with those of other motility disorders.
3. Manometry - It measures the pressure and constriction of the esophageal muscles as food is swallowed. It is used to detect the pattern of muscle activity and the strength of the muscle contractions throughout the esophagus. A barium swallow or fluoroscopy cannot measure the strength of the muscle contractions. Patients with nonspecific esophageal disorders are classified as having hypo contraction abnormalities on manometric examination. Manometric examination reveals an intermittent absence of peristalsis on 20 % or more of the wet swallows (wet swallow causes a higher amplitude of constriction in the distal part of the esophagus than the dry swallow; this is absent in diseases of the esophagus) and low amplitude peristalsis, prolonged duration of peristalsis, and repetitive or three peaked contractions. Disruption of primary peristalsis and non-peristaltic movements are also seen in the radiographic findings.
4. Esophageal Scintigraphy - A non-invasive, easy, sensitive, and specific diagnostic test for determining esophagus abnormalities. It can identify esophageal abnormalities even in asymptomatic patients. NEMD is characterized by normal liquid emptying and delayed semisolid emptying, in contrast to achalasia, where both liquid and semisolid emptying is markedly delayed.
How Is Nonspecific Esophageal Disorder Treated?
Gastroenterologists who deal with such disorders should be aware of the clinical presentations and the interpretation of the diagnostic and therapeutic procedures involved. This is also required of the surgeon, who should be aware of the surgical innovations. Proper planning and awareness of the complications are required for multi-disciplinary follow-up care.
1. Medical Care: The underlying neuropathology causes cannot be cured completely. Hence, the treatment will be at relieving the symptoms elicited. As the nerves involved do not regenerate, treatment is aimed at relieving the physiologic obstruction by surgical or endoscopic balloon disruption of the muscles. A less effective method is to relax the muscles using medications, thereby relieving dysphagia and chest pain.
2. Pharmacologic Care: Smooth muscle relaxants like nitrates and calcium channel blockers were the first drugs used in all cases of this condition. Other drugs used less extensively include anticholinergics, Amyl nitrate, Nitroglycerine, Theophylline, beta antagonists, and, recently, phosphodiesterase inhibitors. Non-chest pain responds well to antireflux therapy, even without gastroesophageal reflux symptoms. In addition, chronic pain management with TPAs (tricyclic antidepressants) effectively manages non-cardiac chest pain, which is resistant to other therapies.
3. Botulinum Toxin Injections: It is a good alternative for poor surgical patients, like the elderly and frail ones. Botulinum toxin is a potent inhibitor of acetylcholine at nerve endings. The main disadvantages associated with this therapy include its cost and the requirement for repeated treatments.
4. Endoscopic Treatment: Esophagogastroduodenoscopy (EGD) with pneumatic dilation is the standard endoscopic treatment for this condition. Balloon dilations are designed specifically for treating patients with non-specific esophageal disorders to achieve adequate diameters with lasting effectiveness. The response rate for this treatment varies from 53 percent to 93 percent. The major complication observed with this procedure is perforation. Therefore, a water-soluble esophagram should be performed post-dilation to ensure no perforation.
5. Surgical Therapy: The VATS approach (video-assisted thoracoscopic surgery) using myotomy and fundoscopy in nonspecific esophageal disorders is a good option for treating cases resistant to medication and balloon dilation.
What Are the Differential Diagnoses for Nonspecific Esophageal Disorder?
The various differential diagnoses for this condition include:
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Achalasia.
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Presbyesophagus.
Conclusion
There is limited knowledge of its natural history and clinical significance, though NEMD is a relatively common disorder. Some patients have been shown to progress toward developing more specific esophageal motility disorders. In approximately one-third of the NEMD patients, esophageal motility has been found to return to normal. Another area of uncertainty in nonspecific esophageal disorders is their clinical significance. The earlier studies suggest that NEMD may be associated with a mild delay in the liquid emptying in some cases, while it was normal in others. These findings were limited by the non-quantitative description of the esophageal transit, the lack of disease control groups, etc. Recent studies performed after overcoming these limitations show that NEMD is associated with a significant but selective impairment of semisolid esophageal emptying.
