Nonobstructive dysphagia is a disorder where there is a sensation of food sticking in the esophagus in the absence of mechanical obstruction in the esophageal body. Symptom evaluation and exclusion of mechanical obstruction is essential for the diagnosis of nonobstructive dysphagia. Evaluation of pathophysiology of nonobstructive dysphagia is targeted at the identification of abnormal transit of the swallowed bolus using such techniques as a transit study or manometry. Classically, transit was evaluated by a barium swallow or scintigraphy. The recent development of a technology combining intraluminal multichannel impedance measurements with manometry allows the evaluation of precise correlations between the passage of the bolus and mechanical function of the esophagus. Also, manometry itself has progressed with the advent of multichannel high-resolution manometry. The interruption of peristaltic propagation in the esophagus may induce dysphagia at the transitional zone or in a diverticulum. More than a half of the patients with nonobstructive dysphagia show dysmotility of the esophagus. Ineffective esophageal motility is the most frequently found abnormality, followed by diffuse esophageal spasm. However, 40% of patients with nonobstructive dysphagia will demonstrate normal motility. Among dysphagia patients with normal motility, some may have abnormal transit. Dysphagia is a common symptom in patients with eosinophilic esophagitis (EoE). EoE patients show decreased distensibility, leading to resistance in the esophagus. Combined impedance and manometry studies in EoE show abnormal bolus transit suggesting the presence of a similar phenomenon in EoE to those with nonobstructive dysphagia. Though the majority of patients with nonobstructive dysphagia have some kind of esophageal dysmotility, its precise pathophysiology is not clear. Firm guidelines for the treatment of nonobstructive dysphagia have not been established, as yet. However, empiric dilatation to a diameter of 15-17 mm may provide good long-term efficacy. This suggests that patients with nonobstructive dysphagia may have some form of esophageal resistance, which might be responsible for the symptom of dysphagia.
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