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Neurogastroenterology & Motility

Neurogastroenterol Motil (2012) 24 (Suppl. 1), 40–47

REVIEW ARTICLE

Weak and absent peristalsis


ANDRÉ SMOUT* & MARK FOX 

*Academic Medical Centre, Amsterdam, The Netherlands


 NIHR Biomedical Research Unit, Nottingham Digestive Diseases Centre, QueenÕs Medical Centre, Nottingham, UK

Abstract
DEFINITIONS AND TERMS
Background Weak and absent esophageal peristalsis
are frequently encountered esophageal motility Until 1997, the term Ônonspecific esophageal motor
disorders, which may be associated with dysphagia abnormalitiesÕ was generally used by physiologists to
and which may contribute to gastroesophageal denote any dysmotility pattern that was not achalasia,
reflux disease. Recently, rapid developments in the spasm, nutcracker or LES dysfunction. Then, Leite
diagnostic armamentarium have taken place, in and coworkers published their finding that Ôineffective
particular, in high-resolution manometry with or with- esophageal motilityÕ (IEM) was the primary finding in
out concurrent intraluminal impedance monitoring. patients with nonspecific esophageal motility disor-
Purpose This article aims to review the current in- der.1 In 2001, this was incorporated into Spechler and
sights in the terminology, pathology, pathophysiology, CastellÕs2 classification of esophageal motor disorders,
clinical manifestations, diagnostic work-up,and based on conventional manometry. In their classifi-
management of weak and absent peristalsis. cation, IEM was defined as distal-esophageal hypo-
contractility in at least 30% of wet swallows,
Keywords absent peristalsis, high-resolution mano-
characterized either as low-amplitude peristaltic
metry, impedance monitoring, ineffective esophageal
waves (<30 mmHg), low-amplitude simultaneous
motility, weak peristalsis.
waves (<30 mmHg) or peristaltic waves that are not
propagated to the distal-esophagus, or absent peristal-
sis. The 30-mmHg criterion was derived from the
observation that amplitudes <30 mmHg were fre-
quently associated with bolus escape and incomplete
Motor abnormalities of the esophagus that fit the
bolus clearance.3
category Ôweak and absent peristalsisÕ are probably the
High-resolution manometry (HRM), with or without
least studied manifestations of esophageal dysfunction,
concurrent intraluminal impedance monitoring,
likely because of the apparent lack of therapeutic
allows a more complete definition of peristalsis. In
options. It is important to recognize that the mano-
the recently developed Chicago classification, frequent
metric diagnosis of esophageal hypomotility does not
failed peristalsis (>30% of wet swallows) is separated
necessarily imply abnormal esophageal transit or pres-
from weak peristalsis (defined as breaks in the 20-
ence of symptoms, including dysphagia.
mmHg isobaric contour). Weak peristalsis with large
defects is judged to be present when breaks >5 cm are
present in >20% of swallows (Fig. 1). Weak peristalsis
Address for Correspondence with small defects is present when breaks of 2–5 cm in
André Smout MD, PhD, Department of Gastroenterology and length are present in >30% of swallows.4 This classi-
Hepatology, Academic Medical Center, PO Box 22700, 1100 fication of manometric abnormalities as abnormal is
DE, Amsterdam, The Netherlands. also based on the likelihood that such defects are
Tel: +31 20 5669111; fax: +31 20 6917033;
associated with esophageal dysfunction (i.e. bolus
e-mail: a.j.smout@amc.uva.nl
Received: 27 August 2011 escape); however, the clinical relevance of such obser-
Accepted for publication: 25 October 2011 vations remains uncertain. Indeed, it is likely that

40 Ó 2012 Blackwell Publishing Ltd


Volume 24, Supplement 1, March 2012 Weak and absent peristalsis

geal hypocontractility (weak, absent or failed peristal-


sis) is the most prevalent finding in clinical series. In
our own experience, IEM with or without hypotensive
LES was found in 58% of 2610 patients referred for
(conventional) manometry. In a series of 350 consec-
utive patients who underwent manometry for various
indications IEM was found in 20.2%.9 IEM was
observed in 27–32% of patients presenting with non-
obstructive dysphagia without GERD.10,11 Hypocon-
tractility is also the most prevalent esophageal motor
disorder in GERD, found in 21–38% of patients in large
series, and its presence is associated with the severity
of acid exposure and reflux symptoms.12,13 Similarly,
in a group of patients with respiratory symptoms
associated with reflux, IEM was found in 53% of
asthmatics, 41% of chronic coughers and 31% of those
with laryngitis.14

PATHOGENESIS AND
PATHOPHYSIOLOGY
In most cases of weak or absent peristalsis identified in
the motility lab the pathogenesis of the motility
disorder will remain unclear. Autopsy studies of the
Figure 1 Examples of high-resolution manometry showing pathology underlying this disordered function are
weak peristalsis with small (2–5 cm) (A) and large (>5 cm) (B) lacking.
breaks in the 20-mmHg isobaric contour. Reproduced with The exceptions to this rule are scleroderma and
permission from Roman et al. Am J Gastroenterol
related connective tissue disorders, in which esopha-
2011;106:349–356.
geal pathology has been studied extensively. There are
three stages in the development of esophageal involve-
several abnormal swallows in series are required before ment in scleroderma: neuropathy, myopathy, and
symptoms are experienced.5 fibrosis.15 The neuronal abnormalities in the first stage
are thought to be the consequence of arteriolar changes
in the vasa nervorum. In the second stage, ischemia
EPIDEMIOLOGY
leads to focal degeneration and atrophy of the muscle
Formally, normal values for esophageal manometry layers. Finally, the muscle tissue is replaced by fibrosis,
should be population-specific and stratified by age and and collagen is deposited. These changes lead to
gender such that, by definition, 5% have hypotensive severely disturbed esophageal motility, in particular
contractions in every group. This quality of data does in the smooth-muscle segment. In advanced disease
not exist. Normal values for conventional manometry manometry shows absent peristalsis, with only simul-
are based on observations in 95 healthy subjects with a taneous pressure waves in the mid- and distal-esoph-
mean age of 43 years (range 22–79 years),6 whereas the ageal body, and low LES pressure. This combination of
two HRM studies upon which the cutoff values for abnormalities leads to increased gastroesophageal
peristaltic breaks were based included only volunteers reflux and impaired esophageal clearance, in particular
under the age of 50.4,7 Data gathered with conventional during the night. Consequently, esophagitis and its
manometry suggest that the amplitude of esophageal complications (ulcer, stenosis and BarrettÕs esophagus)
contractions is higher in men than women, rises with are frequently observed in scleroderma.
increasing age and is higher in Afro-Caribbean than Knowledge about the mechanisms underlying esoph-
Hispanic and Caucasian populations.6,8 This variation ageal hypomotility associated with GERD is accumu-
between demographic and racial groups may be due to lating. In cats with experimentally induced esophagitis,
specific effects of age, gender and race, or common inflammatory mediators, such as interleukin-6 and
factors such as increased outflow resistance caused by platelet activating factor, were found to reduce acetyl-
central obesity. What is beyond doubt is that esopha- choline release from excitatory myenteric neurons.16

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A. Smout & M. Fox Neurogastroenterology and Motility

Similarly, the mucosa of human patients with reflux not provide structural information but is the only
esophagitis produces significantly greater amounts of technique that quantifies esophageal transit.
cytokines than that of healthy controls.17 However, it is Manometry is often considered to be the gold stan-
uncertain whether IEM associated with GERD is dard, being able to detect subtle impairment of esoph-
always the consequence of inflammation. It is also ageal peristalsis. The most characteristic findings in
possible that it is a primary motor disorder leading to scleroderma, low-amplitude simultaneous waves, can
GERD.18 Whereas, animal studies suggest that acute also be observed in other connective tissue diseases and
esophagitis-associated esophageal hypomotility can in diabetes, amyloidosis, myxedema, multiple sclero-
disappear after healing, studies in humans with chronic sis, chronic idiopathic intestinal pseudoobstruction,
erosive GERD have shown that healing of esophagitis, and in severe end-stage GERD without scleroderma.
either medically or surgically, is not associated with Whether conventional or high-resolution manome-
complete recovery of esophageal dysmotility.19,20 try is used, care must be taken to avoid circumstances
Finally, IEM can also be observed in patients without that can lead to a spurious diagnosis of IEM. Examples
any evidence of GERD in present or past. The patho- of these are the use of drugs that inhibit esophageal
genesis of this idiopathic disorder is almost unknown, contractions (anticholinergic agents and calcium chan-
although Kim and coworkers21 have provided initial nel blockers), failure to have an appropriate time
evidence that an imbalance between the excitatory and interval between swallows, and inclusion of dry swal-
inhibitory innervation of the esophagus, reflected in lows. Additionally, depending on the examination
the ratio between choline acetyltransferase (ChAT) and position, the appropriate normal values must be
nitric oxide synthase (nNOS) expressed in the esoph- applied because contractile vigor decreases on moving
ageal muscle wall, may be present in IEM patients. from the supine to the upright position.22
The combination of esophageal manometry and
intraluminal impedance measurement allows assess-
CLINICAL PRESENTATION
ment of the functional impact of ineffective esophageal
Esophageal symptoms in impaired esophageal peristal- contractions. In a study of 350 patients, it was found
sis include dysphagia, odynophagia, heartburn and that one-third of patients with a manometric diagnosis
regurgitation. However, the correlation between the of IEM had ÔeffectiveÕ transit for both liquid and viscous
severity of the manometric findings and the symptoms swallows.9 Similar findings were reported by others,
is extremely poor. Even in patients with complete suggesting that the definition of weak peristalsis
absence of peristalsis, as is often the case in sclero- should include functional correlates.4,23 High-resolu-
derma, symptoms may be absent. On the other end of tion manometry, ideally combined with fluoroscopy or
the spectrum, one can find patients who complain of impedance, clarifies the relationship between dysmo-
severe dysphagia but who have completely normal tility and bolus retention.4,24–26 The introduction of
esophageal peristalsis, LES function, and bolus transit solid swallows or a test meal to manometric studies
on barium studies. may further increase sensitivity to dysfunction associ-
ated with symptoms in ÔfunctionalÕ dysphagia25,26 and
mucosal disease in GERD.27
INVESTIGATIONS
Endoscopic examination of the esophagus is not a
TREATMENT
valuable tool to diagnose esophageal motility; endos-
copy should always be carried out to exclude ulcera- Specific treatment is clearly desirable for patients with
tion, stenosis, and neoplastic lesions before the patient evidence of symptoms related to hypotensive dysmo-
is referred for evaluation of esophageal function. The tility or reflux; however, the options are limited
good old barium esophagogram, still is a useful tech- because there is no pharmacologic intervention that
nique in the work-up of patients with a suspected reliably restores smooth-muscle contractility and
esophageal motility disorder. It will detect obstructive esophageal function. Thus, dietary and lifestyle advice
lesions, esophageal dilation, and hiatus hernia at least together with effective control of acid reflux, if present,
as well as endoscopy. In addition, and most impor- are the mainstays of clinical management.
tantly, the barium esophagogram provides information
about esophageal transit. For this purpose, not only
Dietary and lifestyle management
barium suspension should be used, but swallowing a
solid bolus, such as a marshmallow or a piece of bread, A Ôcommon senseÕ approach can reduce the risk of
should be part of the examination. Scintigraphy does symptomatic bolus retention. Patients should favor

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Volume 24, Supplement 1, March 2012 Weak and absent peristalsis

liquid and semi-solid nutrition over solids, consume directly stimulate muscarinic receptors promote
meals in the upright position, chew well and take smooth-muscle contractility. Bethanechol, a direct-
plenty of fluids as these measures all promote esoph- acting muscarinic receptor agonist, has been shown in
ageal clearance.28 Indeed, it appears that the Ôpharyn- healthy volunteers and patients with hypotensive
geal pumpÕ together with gravity and hydrostatic forces esophageal dysmotility to increase peristaltic ampli-
can move not only liquids but also most solid food tude in the distal-esophagus.39 Using combined mul-
through the esophagus without the need for active tichannel intraluminal impedance- manometry in
esophageal contraction.28,29 Many experts also recom- seven patients with severe IEM, Agrawal and cowork-
mend liberal use of carbonated beverages, because this ers39 demonstrated that a single oral dose of 50 mg
may prevent as well as resolve bolus retention.30,31 bethanechol increased both contractile pressure and
bolus clearance. Similar effects on contractile pressure
were reported by Blonski and coworkers40 for a range of
Treatment of gastroesophageal reflux disease
oral procholinergic agents, including bethanechol
associated with hypotensive dysmotility
(25 mg), pyridostygmine (60 mg), and buspirone
Patients with hypotensive motility with weak lower (20 mg), with pyridostigmine also promoting bolus
esophageal sphincter function often experience severe transport. No trials demonstrating clinical efficacy
symptoms and complications of GERD because poor have been published. Nevertheless, some experts
clearance leads to prolonged acid exposure, particularly report benefit of these medications in individual
at night.15 These problems are marked in patients with patients, although side-effects such as excessive
systemic sclerosis in whom the combination of poor salivation and diarrhea may limit use.
motility and poor salivation impacts on both volume and
chemical (i.e. acid) clearance.32 Dietary and lifestyle Dopamine antagonists Domperidone is a D2 receptor
measures may be helpful, although these are rarely antagonist that promotes gastrointestinal motility by
sufficient in severe GERD. A systematic review identi- antagonizing the inhibitory effects of dopamine on
fied several such interventions that reduce esophageal postsynaptic cholinergic neurons in the myenteric
acid exposure,33 some of which may be of particular plexus.41 Metoclopramide augments this peripheral
benefit in patients with hypotensive dysmotility. These effect with procholinergic properties and also has cen-
included (i) weight loss, (ii) keeping the upper body in an tral anti-emetic actions at the chemoreceptor trigger
elevated position after a meal, (iii) lying down in the right zone.42 These medications increase LES pressure,
lateral position, (iv) not smoking, (v) not consuming accelerate gastric emptying and improve symptoms in
alcohol, (vi) reduction of meal size, and (vii) reduction in patients with GERD and also diabetic gastropare-
calorie load. Reduction in fat intake may be of additional sis.43,44 Effects on esophageal peristalsis and clearance
value as this has high caloric density and also appears to are less well established. No effect of 20 mg domperi-
sensitize the esophagus to acid reflux events.34 In done on esophageal emptying was found on scintigra-
addition, chewing gum for half an hour after meals may phy in 12 patients with diabetic autonomic neuropathy
be helpful,35 as this stimulates salivation and swallow- and esophageal dysfunction.45 In contrast, a significant
ing, improving both volume and chemical clearance. improvement in clearance was reported after adminis-
High-dose acid suppression taken twice a day is tration of 10 mg intravenous metoclopramide in 14
often required to suppress gastric acid, heal esophagitis patients with systemic sclerosis.46
and provide effective symptom relief in patients with
severe hypotensive disease.36 Some patients benefit Motilin agonists Erythromycin and other macrolide
also from alginate preparations taken after the meal antibiotics have pronounced prokinetic side-effects
that suppress both acid and non-acid reflux events by that are utilized by physicians treating patients with
forming a viscous layer over the gastric contents.37 The severe gastrointestinal dysmotility such as gastropare-
addition of ranitidine to suppress basal, nocturnal acid sis and pseudo-obstruction.47 This effect is mediated by
secretion appears to be helpful in individual patients motilin receptors that play a key role in the initiation
but was not effective in a randomized controlled trial of phase III migrating motor complex (MMC), inter-
in 14 patients with systemic sclerosis.38 digestive ÔhousekeepingÕ contractions that sweep the
stomach, and bowel clear of undigested material and
bacterial overgrowth.47 Chrysos and coworkers48
Prokinetics
showed that intravenous erythromycin (200 mg i.v.
Procholinergic agents Medications that increase the bolus) increased contractile vigor and LES pressure in
concentration of acetylcholine in the synaptic cleft or 15 GERD patients, and in a 2-week clinical study

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A. Smout & M. Fox Neurogastroenterology and Motility

Chang and coworkers49 reported that erythromycin acetylcholine release in the myenteric plexus that
(250 mg tid) significantly shortened esophageal and triggers peristaltic contraction and clearance.51 Thus,
gastric transit and improved glycemic control in dia- in contrast to muscarinic antagonists and motilin
betic patients. Although these findings are impressive, agonists, 5-HT4 agonists promote normal gastrointes-
the clinical use of erythromycin is limited by tachy- tinal transit rather than inducing powerful but
phylaxis and side-effects including dyspepsia and diar- unphysiological contractions. These agents have
rhea. New motilin agonists that may be better prokinetic effects throughout the gastrointestinal tract
tolerated are in development. However, one recent and proven clinical efficacy in various conditions
example, ABT-229, had no effect on LES function, characterized by slow-transit, including GERD,
esophageal motility ,and reflux, in GERD patients.50 diabetic gastroparesis and constipation.52 Studies have
demonstrated that cisapride and mosapride increase
Serotonin agonists Cisapride and mosapride are proki- LES pressure, promote esophageal clearance, and
netic agents with mixed 5-HT4 agonist/5-HT3 antago- reduce acid exposure in health and GERD patients.53,54
nist action. Tegaserod, prucalopride, and other However, the mechanism of this action was not
selective 5HT4 agonists have similar actions.42 Sero- evident on conventional motility studies.53–55 Soon
tonin is released from enterochromaffin cells on after the introduction of high-resolution manometry
mechanical stimulation and 5-HT4 receptors facilitate with esophageal pressure topography Staiano and

Figure 2 Concurrent fluoroscopy and


high-resolution manometry (HRM)
reveals the functional importance of
co-ordination between the proximal
and mid-distal esophageal contractions
for solid-bolus transport and the prok-
inetic effects of the 5-HT4 agonist
tegaserod. (A) Patient no. 6: placebo
treatment. HRM shows a break in the
contractile front (>3 cm) at the proxi-
mal transition zone, the peristaltic
contraction is otherwise preserved.
Concurrent fluoroscopy reveals
solid-bolus escape at the level of the
proximal transition zone (note the
corresponding pressure rise at the level
of bolus impaction). In contrast, the
liquid barium ingested with the mars-
hmallow was propelled into the distal-
esophagus and most was transported
into the stomach. (B) Patient no. 6:
tegaserod treatment. The pressure
trough at the proximal transition zone
is less pronounced on the HRM plot,
the peristaltic contraction in the prox-
imal esophagus is well co-ordinated
with the mid- and distal-esophagus.
Concurrent fluoroscopy reveals effec-
tive solid and liquid bolus transport
(note the pressure rise as the bolus
passes through the gastro-esophageal
junction into the stomach). Adapted
with permission from Fox et al.
Aliment Pharmacol Ther 2006; 24:
1017–1027.

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Volume 24, Supplement 1, March 2012 Weak and absent peristalsis

Clouse56 observed that cisapride enhanced contraction may be due to improvement of esophageal motility
in the proximal smooth-muscle segment of the esoph- and visceral hypersensitivity with normalization of
ageal body. The functional significance of this effect acid exposure or due to reduction of the hiatus hernia.
was confirmed by combined HRM-videofluoroscopy However, the literature on the effect of fundoplication
that showed tegaserod improved co-ordination between on esophageal motility and the relationship between
contractile segments, leading to more effective solid- preoperative motility and outcome of surgery should
bolus transport (Fig. 2).57 Cisapride and tegaserod have be interpreted with caution. Flaws in the design of
been withdrawn due to rare, but occasionally life- these studies and manometric techniques employed
threatening, side-effects; however, new 5-HT4 agonists should be taken into account. Some of these studies
are in the pipeline or are in the market approved for concluded that hypotensive dysmotility is not a
other indications.52 Clinical trials in GERD are in contra-indication to surgical management of GERD,
progress and, hopefully, studies in symptomatic, many experts in the field hold the opinion that
hypotensive esophageal motility will follow. fundoplication should not be carried out in patients
with severe IEM.
Surgery
AUTHOR CONTRIBUTIONS
In patients with severe GERD, impaired peristalsis,
impaired esophageal clearance, and dysphagia are AS and MF performed the literature search underlying
common. The dysphagia can be not only due to the this article, analyzed the data and wrote the article.
hypotensive dysmotility3, but also to mechanical
outflow obstruction at the esophagogastric junction
CONFLICT OF INTERESTS
in the presence of hiatus hernia.58 In some cases
anti-reflux surgery may not only improve reflux The authors heave no competing interests.
symptoms but also reduce dysphagia.20,59,60 This

7 Ghosh SK, Pandolfino JE, Zhang Q, Aliment Pharmacol Ther 2003; 18:
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