Q. Esophageal manometry showed LES does not relax all the time. What are the treatment options?

Answered by
Dr. Ajeet Kumar Lohana
and medically reviewed by Dr. Sneha Kannan
This is a premium question & answer published on Oct 17, 2020 and last reviewed on: Jan 21, 2021

Hi doctor,

I have severe heartburn with a feeling of backup in the throat after drinking and eating. The upper endoscopy esophageal manometry showed that LES does not relax all the time and the barium swallow test was normal.

#

Hi,

Welcome to icliniq.com.

Your description coincides with the diagnosis of a gastroesophageal reflux disease where there is repeated unwanted relaxation of LES (lower esophageal sphincter). You can take capsule Esomprzole 40 mg half an hour before breakfast and see for improvement. If you do not have improvement, then confirm the diagnosis of GERD using oesophageal 24-hour metry and consider doing surgical interventions.

Thank you doctor,

I have a feeling that the food or fluid is stuck at the LES. The manometry suggests a symptom of achalasia and there is no enough evidence. I did a barium swallow test and the result was normal. Can I get a botox injection? I heard that it will not be effective and need to get recurrent injections. I do not know whether my doctor agrees to do surgery and there is no enough information to prove it as true achalasia. When it started, I noticed some sudden heartburns.

The doctor suggested me to take Omeprazole 40 mg every morning for sixty-days but I did not have any improvement. Then I did an upper endoscopy and some tests to rule out tumor or cancer and he suggested to continue taking Omeprazole 40 mg. I did not have any improvement and the heartburns persisted.

At this time, I tried sleeping on the left side and it helped me. Then I started to get a feeling that something coming back into the throat after eating or drinking and I had severe burns at night along with a lot of belchings. Then I did a manometry test and the symptoms got worse. The doctor recommended me to have a botox injection to prove achalasia.

But I need to do one more test before taking the decision. Then I did a barium swallow test and it was normal. I got relaxation in LES sometimes and so I thought that the swallow might have captured the image when LES was working normally. Now I am confused and do not know what to do. I am not able to sleep for 4 o'clock due to heartburns and backup feeling. Now sleeping on the left side is not helping me. Please help me.

#

Hi,

Welcome back to icliniq.com.

I can imagine that you are upset at this condition. So, you confirm it as achalasia and not GERD. Both these conditions are the exact opposite of each other. In the former, the LES is unable to relax due to meal bolus and in the latter, there is incompetent relaxation of LES and it causes the acid and food to regurgitate from the stomach into the esophagus. An achalasia patient can have chest burning and it is usually due to food stuck in the LES and it does not allow food to pass across LES in the stomach. The description can help you to understand achalasia. The gold standard test is oesophageal manometry and it helps for diagnosis. Kindly upload the reports of the endoscopy and CT scan if you have done it.

The other close differential is EGJ (esophagogastric junction) obstruction and it can occur due to a tumor in this area. Botox (Botulinum toxin) shows a temporary role and achalasia can come back again. In your case, there are two options to have treatment. The first option is POEM (peroral endoscopic myotomy). This is an endoscopic procedure and it is performed in expert centers. If POEM is not possible, then you can do achalasia balloon dilation. It requires serial endoscopies with dilation of achalasia with ballon. The complications are high.

Thank you doctor,

I have attached the reports of endoscopy and manometry. I am not sure whether I have done all the tests to rule out EGJ. The last endoscopy was done before six months and my complication is getting worse.

#

Hi,

Welcome back to icliniq.com.

Yes, you have done all the necessary tests except a contrast-enhanced CT (computed tomography) scan of the chest with upper abdominal cuts. For EJG obstruction, we have to rule out the pathology outside the lumen of the esophagus. You need to discuss this with the physician next time. As achalasia and EGJ are close differentials, when the EGJ obstruction is gone, there is a development of full-blown achalasia in the future. But your esophageal manometry report shows only EGJ obstruction and there is no evidence of achalasia.

The condition presenting with EGJ obstruction and failed peristalsis result in achalasia. When there is EGJ obstruction with normal peristalsis (in your case), then there is only EGJ pathology and there is no achalasia. It has to be followed by doing a CT scan. I agree with the approach given by your physician and you can use Botox to see for improvement. If there is an improvement, then we can say that it is an initial phase of achalasia in the form of EGJ obstruction. If there is no improvement, then you do not need Botox and you can do a CT scan to confirm EGJ obstruction only and not achalasia.

Thank you doctor,

Does Botox injection does not help for EGJ obstruction? Do I need to discuss with the physician about getting a CT scan before having a Botox? I am worried about the condition getting worse before getting the correct treatment. Is there anything that helps me? I have lost weight in the past six months. I have tried drinking soda or coke to push the food down. It worked in the first but now it does not help me. I have heartburns and chest pain at night. After midnight, my heart beats fast and there is no feeling of backup. But the heartburn is really bad.

#

Hi,

Welcome back to icliniq.com.

Yes, Botox will not help you when EGJ obstruction is secondary to other causes. It will help you only when it is a premature form of achalasia. As I said some patients with pure EGJ obstruction can develop full-blown achalasia in the future. Botox injection seems to be a kind of deciding factor to know the next plan of action. If you have improvement, then your physician can suggest you to have another injection. If there is no improvement, then you need to do a CT scan. The symptomatic improvement can be seen after getting Botox injection on the day of a procedure just after few hours.

I understand the reason for being worried. Achalasia does not progress rapidly and it can remain for years without causing trouble in terms of diet and weight reduction. The acid reflux can cause trouble with achalasia. I suggest you discuss with the physician and do a CT scan before having Botox. Drinking soda and anything cannot help you. You can try taking solid meals. It can pass through LES narrowing in patients with achalasia. A liquid diet has bad effects on achalasia.

Thank you doctor,

Can I take solid meals instead of fluid?

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Hi,

Welcome back to icliniq.com.

Yes, in motility disorders like achalasia, solid meals can work fine. But it is not a rule. You observe the condition. If there is any problem like pain or vomiting, then you can take semi-solids and then liquids.

Thank you doctor,

I have attached the report of the barium swallow test.

#

Hi,

Welcome back to icliniq.com.

It is normal and you have the symptoms with abnormal esophageal manometry.


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