Primary versus secondary esophageal motility disorders: diagnosis and implications for treatment

Ambulatory pH monitoring is essential in patients with a manometric pattern of either diffuse esophageal spasm (DES) or nutcracker esophagus (NE), since these diseases can be considered a primary esophageal motility disorder (PEMD) only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, the motility abnormality is considered secondary, and treatment is directed toward reflux. The aims of this study were to determine in patients with a manometric picture of DES and NE (1) if symptoms alone can distinguish PEMD from GERD and (2) the value of ambulatory pH monitoring. A total of 180 patients fulfilled the manometric criteria for NE, and 124 (69%) of them had GERD detected by ambulatory pH monitoring. Among the 56 patients with PEMD, 31 (55%) were taking proton pump inhibitors on the assumption that GERD was present. Chest pain prevalence was similar when the two groups were compared; however, the symptom was more severe in the PEMD patients. Heartburn prevalence and severity was higher in the GERD group. A total of 121 patients fulfilled the manometric criteria for DES, and 73 (60%) of them had GERD detected by ambulatory pH monitoring. Among the 48 patients with PEMD, 39 (81%) were taking proton pump inhibitors. Dysphagia was more prevalent in the PEMD group. These data show that (1) 2 of 3 of patients with a manometric picture of NE or DES have GERD and (2) symptoms did not distinguish PEMD from GERD. Esophageal manometry and pH monitoring are essential to distinguish PEMD from GERD and to guide appropriate therapy.