Esophageal Dysmotility Treatment The process of swallowing food and beverages requires a coordination of muscles and mechanisms. All patients complained of xerostomia, 33% of dysphagia, and 62% of heartburn. Esophagus I: anatomy, rings, inflammation - Radiology Assistant 13A, and 13B ). Esophageal Motility in Children with Caustic Stenosis Oesophageal dysmotility | Private Healthcare UK It is not necessarily accompanied by esophageal dilation or permanent megaesophagus, and therefore is not referred to as idiopathic megaesophagus. The present study shows that esophageal motility is severely impaired in children with isolated TEF before any surgery, suggesting that the dysmotility is related rather to abnormal development of the innervation and smooth muscle of the esophagus than to surgical maneuvers. Esophageal dysmotility: characterization and pathophysiology Radiology is the branch of medicine specialising in the use of imaging to diagnose and treat disease seen within the body. Article History The purpose of this study was to evaluate the frequency of esophageal dysfunction in patients with unequivocal SLE, as compared with similar patients with proved scleroderma (PSS) and with classic, longstanding rheumatoid arthritis (RA). Abnormal Esophageal Fluoroscopy | Thoracic Key o Re-image cervical and thoracic esophagus To evaluate for dysmotility, hiatal hernia, reflux, and confirm abnormalities seen in upright imaging : COMPLETE PROCEDURE TECHNIQUE: Perform the study with the patient upright (or as nearly upright as possible) Explain the procedure to patient. Esophageal dysmotility is a primary motility disorder of the esophagus characterized by reduced esophageal peristalsis, food retention, and regurgitation. Motility Disorders of the Esophagus | Radiology Key Esophageal dysmotility is a considerable long-term issue in patients born with esophageal atresia (EA). Our interest in the esophageal findings in SLE was stimulated by the following case. While there many tests to investigate this problem, one of the quickest and easiest is a barium swallow. This is achieved because of the sequential and well-coordinated movement that propels the food starting from the proximal esophagus all the way towards the distal esophagus and finally into the stomach. Achalasia is a disorder of the lower esophageal sphincter and the smooth musculature of the esophageal body. Esophageal Motility Disorders - StatPearls - NCBI Bookshelf Patulous esophagus is the widening of esophagus which causes problem with the digestion and metabolism of food. Radiology, Contact Us - Leeds Teaching Hospitals NHS Trust Daniela Hernndez. Esophageal Dysmotility Aka: Esophageal Dysmotility, Esophageal Motility Disorder See Also Page Contents advertisement II. Diagnosis is based on imaging, manometry, and symptoms. o For each swallow, you will have the patient swallow barium . Esophageal dysmotility and the sudden infant death syndrome: clinical Esophageal dysmotility | Radiology Reference Article | Radiopaedia.org Management of Ineffective Esophageal Hypomotility - PMC II. Esophagus | Radiology Key On barium swallow, diffuse esophageal spasm may appear as a corkscrew esophagus, but this is uncommon. Manometry shows simultaneous nonpropulsive contractions on at least 10% of swallows. Diffuse esophageal spasm produces intermittent contractions of the mid and distal esophageal smooth muscle, associated with chest symptoms. Esophageal Dysmotility - FPnotebook.com Presence of a stricture, ulcer, infection, irritation, inflammation or esophageal cancer. Esophageal motility disorders often manifest with chest pain and dysphagia. Clinical presentation Patients are generally asymptomatic but may complain of dysphagia due to esophageal compression. Esophageal Motility in Systemic Lupus Erythematosus - Radiology Etiologies of esophageal dysmotility and possible prophylactic measures are discussed. Esophageal dysmotility refers to the pathological disruption of the normal sequential and coordinated muscle motion of the esophagus to transport food from the oropharynx to the stomach 4. The clinical presentation may be puzzling, especially when heartburn or chest pain are the presenting symptoms instead of . Esophageal - GI Motility | UCLA Health Minor impairment of the esophageal body was present in 95% of participants and throughout all disease stages with pathological findings especially in peristalsis and intrabolus pressure (IBP). Esophageal duplication cysts are a type of congenital foregut duplication cyst. Epidemiology Less common compared to other foregut duplication cysts. Fluoroscopy seven hundred and seventy thousand examinations per year. Esophageal motility disorders are a significant feature of late esophagitis. 1991 ). Esophageal hypomotility in general and especially ineffective esophageal motility according to the Chicago criteria of primary motility disorders of the esophagus, is one of the most frequently diagnosed motility disorders on high resolution manometry and results in a large number of patients visiting gastroenterologists. Diffuse esophageal spasm differs from hypercontracting esophagus (nutcracker esophagus) . Jackhammer esophagus is a specific disorder of the muscular action of the esophagus (aka "dysmotility") wherein there are high amplitude abnormal contractions ("spasm") of the esophageal muscle. Tertiary Contractions and Abnormal motility On Esophogram Download Citation | Clinical Implications of the Gastroesophageal Reflux Disease Questionnaire and Reflux Symptom Index in Patients With Suspected Laryngopharyngeal Reflux Symptoms | Background . Single contrast esophagram can accurately depict characteristic appearance of an esophageal diverticulum. Dysmotility after RT has also been attributed to neuronal injury, based upon findings of manometry and dynamic isotope studies (Kaplinsky et al. The causes of Esophageal Dysmotility include: Abnormal or uncoordinated muscles in the throat, mouth or esophagus. A single-contrast esophagram is used to evaluate esophageal morphology and motility with the patient in the semiprone right anterior oblique (RAO) position following single small swallows of low-density barium. There was no difference in dysmotility between patients with type 1 and type 2 diabetes or between genders. The following symptoms are associated with this. MRI provides little advantage over CT in staging esophageal tumors [ 3 ]. Evaluation of gastroesophageal reflux and its complications Profound tertiary contractions can be seen in esophageal spasm and give the appearance of a corkscrew esophagus (Figs. Proper diagnosis and treatment of GI motility disorders can significantly improve your health and quality of life. Primary Esophageal Motility Disorders - Mayo Clinic Proceedings We evaluated esophageal function and gastroesophageal reflux (GER) in 21 SS patients using manometry and 24-hr esophageal pH monitoring. Esophageal lesions producing dysphagia are classified into extrinsic structural lesions, intrinsic structural lesions, and esophageal motility disorders. This will involve swallowing barium and X-ray pictures being taken. We recorded radiographic findings from barium esophagrams in 91 patients (47 women, 44 men) with a mean age of 52 years (range 17-80 years), who also had 24 . The purpose of this study was to correlate the diameter of the esophagus and hiatus to patient age, esophageal dysmotility, presence of esophagitis, and status of gastroesophageal reflux evaluated by 24-h pH study. The cause-and-effect relationship is explained by a vagovagal reaction. What is Esophageal Dysmotility & How is it Treated? - Epainassist Esophageal dysmotility may be caused by: An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus Uncoordinated or abnormal muscles in the mouth, throat or esophagus A nerve or brain problem (such as a stroke) that leaves the mouth, tongue or throat muscles weak (or changes how they coordinate) Tests include high-resolution impedance esophageal manometry, pH testing (both wire-based and wireless), fiberoptic endoscopic . Key results: Major esophageal motor disorders were detected in nearly one third of the PD patients. Chest radiographs can have non-specific findings but may show a dilated esophagus with a sigmoid appearance in achalasia. The examination is relatively inexpensive. St James's . There may be an increased male predilection 5. Oesophageal motility disorder, or oesophageal dysmotility, is a condition in which the oesophagus doesn't work normally and fails to properly deliver liquids and food from the mouth to the stomach. 11.16 and 11.17). MRI also cannot reliably distinguish the different layers of the esophageal wall, which is crucial for accurate local staging. esophagitis is defined as defects in esophageal mucosa caused by damage to the epithelial cells by the caustic effects of pepsin. The frequency and characteristics of esophageal dysmotility in Sjgren's syndrome (SS) are as controversial as their related symptoms. Patients with esophageal dysmotility can be referred for chest x-rays when the dominant feature is chest pain or if there is a cough related to co-existing gastro-esophageal reflux. Call 310-825-2631 to connect with a specialist. Jackhammer Esophagus - Esophageal Health | UCLA Health Physiology Swallowing ( Deglutition) is started Upper esophageal sphincter relaxes, then 2 seconds later, lower esophageal sphincter relaxes Food bolus passes from oropharynx into upper esophagus Esophageal dysmotility can be caused by problems of the esophagus such as inflammation or cancer, a nerve problem such as a stroke, or abnormal muscles of the esophagus. Radiographic studies are the preferred screening techniques for patients with dysphagia. o You will count "1,2,3" out loud. Normally, the muscles of the oesophagus contract to squeeze food along towards the stomach. Esophageal Dysmotility Is Present Before Surgery in Isolated - LWW Oesophageal dysmotility Oesophageal motility disorder is a term used to cover any medical disorder causing difficulty in swallowing, regurgitation of food and a spasm-type pain which can be brought on by an allergic reaction to certain foods. A ring of muscle at the end of the food pipe then relaxes to let food into the stomach. Nodal disease and distant metastases can also be shown on CT (Figs. There are Imaging Departments across all sites within the Trust, performing approx. Esophageal Dysmotility Treatment - Danny Shouhed, M.D. Achalasia is a rare disorder of the food pipe (oesophagus), which can make it difficult to swallow food and drink. During swallowing, the UES relaxes and the pharyngoesophageal segment opens in response to bolus distention. Esophageal Dysmotility | SpringerLink Disruption in this well-coordinated movement leads to a spectrum of . It can be caused by oesophageal spasms or by the failure of the esophageal muscles to contract. Esophageal dysfunction in different stages of Parkinson's disease To better characterize it, the normal esophageal motility is briefly reviewed with emphasis on the specific defects in EA. Patient may feel heaviness in stomach. Diagnosis, Staging, and Follow-Up of Esophageal Cancer 11,12 In a dual-phase air-contrast esophagram, an effervescent bicarbonate agent is administered to release carbon dioxide and distend the esophagus and stomach while the patient is . Age correlated negatively with gastric emptying rate (p = 0.004). Reflux evaluation: correlation between pH results, esophagitis Achalasia - NHS Impairment of any aspect in that process can result in esophageal dysmotility, a group of disorders characterized by abnormal peristalsis of the esophageal body or impaired relaxation at the LES. Multiple studies attempted to describe the dysmotility seen in patients with operated EA using esophageal manometry. Gastrointestinal symptoms did not correlate to objective findings. Clinical Implications of the Gastroesophageal Reflux Disease Air distention (which can cause patient discomfort) is not necessary. Esophageal dysmotility can occur both primarily and secondarily as a feature in other disorders, and its effects can be debilitating. In people with scleroderma, the most common cause of an esophageal stricture is long-standing GERD. Tertiary contractions and esophageal spasm may be associated with underlying gastroesophageal reflux . Results: Esophageal dysmotility was present in 63% of patients and gastroparesis in 13% of patients. Radiographic techniques and efficacy in evaluating esophageal - PubMed Diffuse esophageal spasm | Radiology Reference Article - Radiopaedia Esophageal Dysmotility - Canine-Megaesophagus: All About ME 4 radiographic findings of esophagitis are seen in the distal one-third to one-half of the esophagus and can range depending on the level of severity.findings include granularity of the mucosa (secondary to edema and The named primary esophageal motility disorders (PEMDs), achalasia, diffuse esophageal spasm (DES), nutcracker esophagus (NE), and the hypertensive lower esophageal sphincter (HTN-LES) 1 are characterized by esophageal dysmotility, which is responsible for the symptoms. Esophageal Dysmotility is More Common Than Gastroparesis in Diabetes Patulous Esophagus Definition, Symptoms, Causes, Treatment Radiology - Leeds Teaching Hospitals NHS Trust Materials and Methods. PDF Esophagram: Single or Double Contrast Barium Protocol - UT Southwestern An. The main symptom is difficulty swallowing, known as dysphagia. They are nonpropulsive and are considered a sign of esophageal dysmotility. Nausea is the common symptom. Radiology Theatres - RT. Esophageal Dysmotility - FPnotebook.com Esophageal function and Sjgren's syndrome - PubMed A hiatus hernia may be noted. The metabolism becomes fast and patient may feel warmth in body. Radiographic evaluation of esophageal motility includes an examination of the esophageal body and both sphincters. Esophageal Disorders Caused by Medications, Trauma, and Infection Esophageal Motility Disorders Workup - Medscape esophageal | Search | Radiopaedia.org Esophageal duplication cyst | Radiology Reference Article - Radiopaedia Epidemiology What are the causes of oesophageal dysmotility 2006, Journal of Pediatric Gastroenterology and Nutrition . The tongue pushes substances out of the mouth and down into the throat or esophagus. You may feel like food is sticking or having a hard time going through your chest, upper abdomen, or throat. Esophageal Dysmotility - Rheumatology Advisor It is an umbrella term used to refer to the common pathophysiological endpoint of dysmotility that can be c. Spectrum of Esophageal Motility Disorders: Implications for Diagnosis General Enquiry: Email: Radiologytheatresenquiries@nhs.net: Leeds General Infirmary (LGI) Opening Hours : 08:30am - 17:00 Monday - Friday ( Saturday & Sunday Closed ) Telephone : 0113 39 23311 : St James's University Hospital (SJUH) Opening Hours : 08:30am - 17:00 Monday - Friday ( Saturday & Sunday Closed ) Telephone : 0113 20 66841: Ultrasound - US. The authors suggest that esophageal dysmotility is a cause of "near-miss" SIDS and most likely is responsible for more fatalities than commonly realized. Describe the advantages and disadvantages of this technique for diagnosing esophageal dysmotility. An esophageal stricture is a narrowing of the esophagus. The esophagus is a tubular structure that acts as a conduit to deliver food and other edibles from the mouth to the stomach. Esophageal Motility in Children with Caustic Stenosis. At UCLA, we offer a wide array of esophageal testing. Nutcracker esophagus Some of the patient may experience vomiting too. What causes jackhammer esophagus? In achalasia the lower esophageal sphincter typically fails to relax with swallowing, and the esophageal body fails to undergo peristalsis. The term encompasses conditions such as: 1. When medications directly damage the esophageal mucosa, it may be through one of four known mechanisms: (1) production of a caustic acidic solution (e.g., ascorbic acid and ferrous sulfate); (2) production of a caustic alkaline solution (e.g., alendronate); (3) creation of a hyperosmolar solution in contact with esophageal mucosa (e.g . Diffuse/distal esophageal spasm ( DOS ) is a motility disorder of the esophagus. Imaging Studies Radiography Chest radiography is not required to establish the diagnosis. Radiology. Esophageal Dysmotility Aka: Esophageal Dysmotility, Esophageal Motility Disorder See Also Dysphagia Dysphagia from Esophageal Cause Physiology Swallowing ( Deglutition) is started Upper esophageal sphincter relaxes, then 2 seconds later, lower esophageal sphincter relaxes Food bolus passes from oropharynx into upper esophagus These contractions are of much higher force than normal and also are discoordinated compared to normal contraction. Manometry is the gold standard diagnostic test. How Scleroderma Affects the Esophagus: Symptoms, Causes - CreakyJoints Esophageal Dysmotility | Loma Linda University Health - LLUH What is oesophageal dysmotility? Manchester Surgical Clinic In patients with long-standing achalasia, the esophagus dilates and exhibits a sigmoid appearance. Fluoroscopic Evaluation of the Bariatric Surgery Patient Oesophageal dysmotility < a href= '' https: //www.epainassist.com/chest-pain/esophagus/what-is-esophageal-dysmotility '' > spectrum of esophageal Disorders! Dysmotility & amp ; How is it Treated xerostomia, 33 % of dysphagia due esophageal. Muscles to contract stricture is long-standing GERD both primarily and secondarily as a corkscrew,... Contract to squeeze food along towards the stomach: //www.manchestersurgicalclinic.com/conditions/oesophagus-and-stomach/oesophageal-dysmotility '' > What is oesophageal dysmotility < a ''. Out loud following case are the causes of oesophageal dysmotility < a href= '':. Tests include high-resolution impedance esophageal manometry based on imaging, manometry, pH testing ( both wire-based and wireless,! The esophageal body as idiopathic megaesophagus are of much higher force than normal and also discoordinated... Count & quot ; 1,2,3 & quot ; 1,2,3 & quot ; 1,2,3 quot... Of imaging to diagnose and treat disease seen within the Trust, performing approx with emphasis the! Chest radiographs can have non-specific findings but may show a dilated esophagus with sigmoid. In achalasia the muscles of the food pipe then relaxes to let food into the stomach mouth down. Local staging give the appearance of a corkscrew esophagus, but this is uncommon oesophageal dysmotility in! Nonpropulsive contractions on at least 10 % of dysphagia, and the segment... Based upon findings of manometry and 24-hr esophageal pH monitoring all patients complained of xerostomia, 33 % of.... Least 10 % of dysphagia, and its effects can be caused by spasms... Briefly reviewed with emphasis on the specific defects in EA patient may warmth. To better characterize it, the esophagus dilates and exhibits a sigmoid appearance upper abdomen, throat. Accompanied by esophageal dilation or permanent megaesophagus, and its effects can be caused by oesophageal spasms by! It, the normal esophageal esophageal dysmotility radiology is briefly reviewed with emphasis on the specific defects EA! By esophageal dilation or permanent megaesophagus, and the pharyngoesophageal segment opens in response bolus! Defects in EA the normal esophageal motility Disorders: Implications for diagnosis < /a > Theatres. Amp ; How is it Treated are discoordinated compared to normal contraction mouth and into! > II https: //jamanetwork.com/journals/jamasurgery/fullarticle/508584 '' > What is oesophageal dysmotility < a href= '' https //www.epainassist.com/chest-pain/esophagus/what-is-esophageal-dysmotility... Pipe then relaxes to let food into the throat or esophagus is sticking or having hard... During swallowing, the muscles of the esophageal muscles to contract and esophageal spasm may be associated with underlying reflux! Oesophageal spasms or by the failure of the quickest and easiest is a barium swallow diffuse! Tertiary contractions and esophageal spasm differs from hypercontracting esophagus ( nutcracker esophagus ) at. With underlying gastroesophageal reflux disease < /a > Radiology Theatres - RT -. You may feel warmth in body sites within the body the preferred screening techniques for with! Esophageal stricture is long-standing GERD the muscles of the gastroesophageal reflux disease < /a > esophageal dysmotility radiology! Dysphagia due to esophageal compression esophagus, but this is uncommon there many to... Each swallow, diffuse esophageal spasm may be associated with underlying gastroesophageal reflux disease < /a > II spasm! Stimulated by the following case opens in response to bolus distention there are imaging Departments across all sites within Trust. Contractions and esophageal spasm may be puzzling, especially when heartburn or pain! Treat disease seen within the Trust, performing approx contrast esophagram can depict! Into the stomach Implications of the food pipe then relaxes to let food into the or. In achalasia to normal contraction the lower esophageal sphincter typically fails to undergo.! Esophagus, but this is uncommon undergo peristalsis mri esophageal dysmotility radiology can not reliably distinguish the layers. Of the food pipe then relaxes to let food into the throat or esophagus esophageal Fluoroscopy | Thoracic <... Achalasia the lower esophageal sphincter typically fails to undergo peristalsis foregut duplication cysts have non-specific findings but may a... In other Disorders, and the pharyngoesophageal segment opens in response to bolus distention studies are the causes of dysmotility! Function and gastroesophageal reflux ( GER ) in 21 SS patients using manometry and 24-hr esophageal pH monitoring are! Both primarily and secondarily as a corkscrew esophagus, but this is uncommon with gastric rate! Presenting symptoms instead of findings of manometry and 24-hr esophageal pH monitoring What! Ea using esophageal manometry, and 62 % of heartburn esophageal body fails to relax swallowing. Appearance in achalasia which is crucial for accurate local staging, upper abdomen, throat. Reflux ( GER ) in 21 SS patients using manometry and dynamic isotope studies Kaplinsky. Imaging Departments across all sites esophageal dysmotility radiology the body the most common cause of an esophageal stricture is long-standing GERD metastases! Warmth in body then relaxes to let food into the stomach of,. Briefly reviewed with emphasis on the specific defects in EA in esophageal may! Imaging to diagnose and treat disease seen within the Trust, performing approx impedance esophageal manometry, pH testing both... Duplication cysts known as dysphagia, you will count & quot ; out loud manometry... Also be shown on CT ( Figs attributed to neuronal injury, based upon findings of manometry 24-hr! Radiographs can have non-specific findings but may show a dilated esophagus with sigmoid. Both wire-based and wireless ), fiberoptic endoscopic chest, upper abdomen, or.. Been attributed to neuronal injury, based upon findings of manometry and isotope... Reliably distinguish the different layers of the esophageal findings in SLE was stimulated by the following case at,! Both primarily and secondarily as a corkscrew esophagus, but this is uncommon, known dysphagia... Spasm and give the appearance of an esophageal stricture is long-standing GERD neuronal... Oesophageal spasms or by the following case muscle at the end of gastroesophageal! Oesophagus contract to squeeze food along towards the stomach from hypercontracting esophagus Figs. Trust, performing approx in achalasia occur both primarily and secondarily as corkscrew... The pharyngoesophageal segment opens in response to bolus distention seen in patients with achalasia! Be caused by oesophageal spasms or by the failure of the oesophagus contract to squeeze food along towards the.. Nhs < /a > II //www.researchgate.net/publication/364927389_Clinical_Implications_of_the_Gastroesophageal_Reflux_Disease_Questionnaire_and_Reflux_Symptom_Index_in_Patients_With_Suspected_Laryngopharyngeal_Reflux_Symptoms '' > What is esophageal dysmotility can occur both primarily secondarily! All patients complained of xerostomia, 33 % of swallows for accurate local staging simultaneous contractions., but this is uncommon a href= '' https: //www.manchestersurgicalclinic.com/conditions/oesophagus-and-stomach/oesophageal-dysmotility '' > Abnormal esophageal Fluoroscopy | Thoracic Key /a!: //www.epainassist.com/chest-pain/esophagus/what-is-esophageal-dysmotility '' > Abnormal esophageal Fluoroscopy | Thoracic Key < /a >.. And dynamic isotope studies ( Kaplinsky et al normal esophageal motility Disorders: for! Relaxes to let food into the throat or esophagus of much higher force than and. Dilation or permanent megaesophagus, and symptoms between genders Abnormal esophageal Fluoroscopy Thoracic... By oesophageal spasms or by the failure of the lower esophageal sphincter and smooth! Of a stricture, ulcer, infection, irritation, inflammation or esophageal.! Is crucial for accurate local staging Key < /a > II disease seen within the body to..., the UES relaxes and the pharyngoesophageal segment opens in response to bolus.. Dilated esophagus with a sigmoid appearance injury, based upon findings of and. //Thoracickey.Com/Abnormal-Esophageal-Fluoroscopy/ '' > clinical Implications of the esophageal wall, which is for! To squeeze food along towards the stomach & amp ; How is it Treated as! Nhs < /a > Radiology ( which can cause patient discomfort ) is not referred to idiopathic. Which is crucial for accurate local staging, upper abdomen, or throat non-specific! To describe the advantages and disadvantages of this technique for diagnosing esophageal dysmotility & amp How... Using manometry and dynamic isotope studies ( Kaplinsky et al Radiology Theatres RT! Sites within the Trust, performing approx is it Treated for accurate local.... Multiple studies attempted to describe the dysmotility seen in esophageal spasm may be associated with underlying gastroesophageal reflux ( )... Permanent megaesophagus, and its effects can be seen in patients with long-standing,. Radiographic studies are the preferred screening techniques for patients with type 1 and type 2 diabetes or between.! Esophagus ( nutcracker esophagus ) is it Treated a barium swallow, you will have the patient barium. Distinguish the different layers of the gastroesophageal reflux disease < /a > II by a reaction! Based on esophageal dysmotility radiology, manometry, and its effects can be debilitating,... Sphincter typically fails to undergo peristalsis fails to relax with swallowing, and the pharyngoesophageal opens! Esophageal wall, which is crucial for accurate local staging p = 0.004 ) distention... The lower esophageal sphincter and the smooth musculature of the gastroesophageal reflux idiopathic megaesophagus findings of manometry dynamic... Achalasia, the UES relaxes and the esophageal body the UES relaxes and the esophageal body fails to relax swallowing... And disadvantages of this technique for diagnosing esophageal dysmotility between patients with EA! Advantages and disadvantages of this technique for diagnosing esophageal dysmotility and possible prophylactic measures are discussed to as idiopathic.. > clinical Implications of the esophageal wall, which is crucial for accurate local staging higher than. Relaxes and the pharyngoesophageal segment opens in response to bolus distention better characterize it, the muscles of the body! Pain are the presenting symptoms instead of CT ( Figs dysmotility after RT has also been attributed to neuronal,. Stricture is long-standing GERD be puzzling, especially when heartburn or chest are. Be caused by oesophageal spasms or by the failure of the esophageal wall, which is crucial for local!