Functional disorders of the esophagus: current concepts and diagnoses.

Several papers have reported [1] about "functional disorders of the esophagus" in European countries and the USA; however, few reports on these disorders have been found in Japan except concerning achalasia [2]. Having an opportunity to study with Dr. DeMeester, a well-known surgeon in this field, I had the personal experience of measuring the esophageal motility and pH recording in many patients with these disorders from June 1987 to August 1988 in Omaha, Nebraska, USA. The question I kept asking myself during this period in the USA was why there were so few reports about benign esophageal disorders in Japan and why gastroenterologists in Japan had so little interest in these clinical entities. In other words, is there, in fact, low incidence of these disorders among Japanese or is there simply no concern with these diseases among Japanese gastroenterologists? The only way to clarify this question is to measure esophageal motility and pH monitoring in patients with dysphagia, non-cardiac chest pain or heartburn in Japan, too. It is also important to perform the examination in the same way as occidentals do and to compare our results with theirs. As there is confusion about the criteria for the definition and name of these disorders in Japan, it may be necessary to define these relatively new clinical concepts as follows. Functional disorders of the esophagus are defined as the disorders of the esophagus that are not derived from organic diseases such as malignant or benign tumor, diverticulum or stricture. Since the function of the esophagus is to transport material from the mouth to the stomach, functional disorders are related to disturbance of motility. They are classified as primary or secondary. Primary functional disorders may be subdivided into the three anatomical regions: upper, middle, and lower esophagus. Neuromuscular diseases cause motility disorders in the pharyngeal region, diffuse esophageal spasm (DES), nutcracker esophagus (high amplitude peristalsis), which is a disorder of the esophageal body, and achalasia or hypercontracting sphincter, a dysfunction of the lower esophageal sphincter (LES). Secondary functional disorders include motility disorders derived from gastroesophageal reflux (GER) or collagen vascular diseases. To make a precise diagnosis of functional esophageal disorders, specific diagnostic tests are required in addition to a detailed history and physical examination. In practice, these include video roentgenographic barium studies and endoscopy, esophageal manometry, 24-hour pH monitoring, and sometimes ambulatory esophageal motility. Manometry may be performed using a perfused multi-lumen catheter connected to a pneumohydraulic capillary infusion pump. The amplitude, duration, propagation, and efficiency of contractions in the esophageal body as well as the incidence of abnormal contractions may be recorded manually or by a computer. The location, length, pressure, and percentage relaxation of the LES are recorded. The purpose of manometry is twofold: first, to record esophageal motor