Major Motility Abnormality (MMA): A Needed But Unusual Category of Esophageal Dysmotiliy

Abstract

Background: A small group of patients with esophageal motility abnormalities including achalasia are difficult to diagnose definitely with esophageal manometry. In our laboratory we invoke the term “major motility abnormality” (MMA) to incorporate diagnosis of two motility disorders with overlapping features, while conveying a message to the referring physician that the manometry is definitely abnormal. The aim of this study was to investigate the role of barium esophagram (BE) as the next step in helping to sort out the diagnosis in this group of patients.

Methods: A retrospective review was performed of high resolution manometry (HRM) studies performed in our laboratory over 27 months from Aug 2012-Oct 2014 to identify the eventual diagnosis of patients with MMA, with special interest in those who have achalasia as one of the potential diagnosesonmanometry. BE interpretation was performed by a single radiologist blinded from manometry results. Criteria used to exclude achalasia were presence of primary peristalsis, esophago-gastric junction (EGJ) diameter greater than 12.5 mm to exclude a typical “bird beak”, and esophageal dilatation.

Results: 68 of 1971 (3.4%) patients seen in our Esophageal Disorders clinic were diagnosed asMMA by HRM;29/68 (42.6%) had achalasia as a potential manometric diagnosis. BE interpretation was felt to exclude achalasia in 25/29 (86%) of these patients. 14/29 had features of achalasia and Ineffective Esophageal Manometry (IEM); BE was felt to rule out achalasia in all of them (100%). 11/29 had features of achalasia and distal esophageal spasm (DES); BE showed no achalasia in 8/11 (72%). 4/29 had features of achalasia and scleroderma; BE excluded achalasia in 3/4(75%).

Conclusion: MMA is an unusual motility diagnosis we find helpful when HRM is confusing. We believe that BE is an important complementary diagnostic test to rule out achalasia in patients with an ambiguous manometry study finding of MMA. Do not forget the BE!!