Treating an esophageal disorder comes down to two problems: reflux of gastric contents into the esophagus, and failure of the esophagus to contract normally or to relax its lower sphincter. Because the symptoms of these problems overlap, treatment follows the diagnosis reached by endoscopy, manometry and reflux testing rather than the symptom alone.
Reflux disease
When reflux is mild or intermittent, measures that reduce reflux and acid exposure come first: losing weight in a patient who is overweight, not eating within 2 to 3 hours of going to bed, and raising the head of the bed for symptoms that wake the patient at night. These rarely abolish symptoms on their own, but they are worth combining with drug treatment.
Proton pump inhibitors (PPIs) are the medical treatment of choice. They are taken before a meal, usually for a course of about 8 weeks. If symptoms persist, adherence and the dose or timing are checked before the drug is called a failure, and the diagnosis is reconsidered rather than simply escalating treatment. H2-receptor antagonists and antacids have a smaller, shorter effect and are used for milder or breakthrough symptoms.
When symptoms persist despite an adequate trial of a PPI, the next step is to confirm that reflux is really the cause, usually with ambulatory reflux monitoring, before surgery or an endoscopic procedure is considered. For patients with objectively confirmed reflux who do not want long-term medication or who have troublesome regurgitation, laparoscopic fundoplication — wrapping the fundus of the stomach around the lower esophagus to reinforce the barrier — and endoscopic antireflux procedures are options.
Untreated or long-standing reflux can cause erosive esophagitis, peptic stricture and Barrett esophagus, so symptoms that persist despite treatment are re-evaluated rather than suppressed indefinitely.
Motility disorders
In achalasia the lower esophageal sphincter fails to relax and peristalsis is lost, so food is held up at the junction with the stomach. Treatment therefore aims to lower the sphincter pressure rather than to restore body contraction.
Three methods do this: pneumatic balloon dilation, which tears the sphincter by inflating a balloon across it; laparoscopic Heller myotomy, which cuts the sphincter muscle and is usually combined with a partial fundoplication to limit reflux; and peroral endoscopic myotomy (POEM), which performs the same muscle cut from within the esophagus, without an external incision. All three are effective; the choice depends on the patient’s age, the achalasia subtype determined by manometry, and local expertise. Botulinum toxin injected into the sphincter gives temporary relief and is reserved for patients who cannot undergo one of these definitive treatments.
The spastic motility disorders, diffuse esophageal spasm and hypercontractile esophagus, are less well understood, and their symptoms do not always match the manometric findings. Smooth-muscle relaxants such as nitrates and calcium channel blockers, and low-dose tricyclic antidepressants, are used to reduce symptoms, though the evidence for them is limited; peroral endoscopic myotomy can be considered in severe, refractory cases.