Synopsis
Differentiate major oesophageal motor disorders from structural, cardiac and functional mimics, then use physiology-led, proportionate specialist treatment.
- Oesophageal chest pain and dysphagia have structural, inflammatory, reflux, cardiac and functional causes; motility testing follows appropriate exclusion rather than replacing it.
- High-resolution manometry classifies motor patterns using pressure topography, but a technically named pattern is clinically meaningful only when symptoms and supportive evidence align.
- Distal oesophageal spasm features premature contractions with preserved oesophagogastric junction relaxation, whereas type III achalasia combines premature activity with impaired relaxation.
Key red flags
Squeezing retrosternal pain may occur with swallowing or at rest, but cardiac and aortic emergencies require appropriate exclusion before oesophageal spasm is considered.
Investigation priorities
Exclude myocardial ischaemia or another cardiovascular emergency during acute chest pain.
Management branches
A patient reports unexplained dysphagia or recurrent oesophageal-type chest pain.
- Triage acute coronary, aortic, obstructive and perforation features first, and use urgent pathways rather than elective physiology when present.
- Review symptom consistency, reflux, impaction, weight, systemic disease and medicines, especially prescribed or non-prescribed opioids.
Key medicines
Proton pump inhibitor for documented refluxUse a licensed full-dose PPI regimen from the current BNF for an adequate initial course, then step down or continue according to objective reflux, mucosal injury and symptom benefit.
Smooth-muscle relaxant such as a nitrate or calcium-channel blockerIf a physiology specialist recommends an off-label trial, use the exact current BNF and local protocol for the chosen product, beginning cautiously and reviewing benefit promptly; no regimen applies universally across spastic phenotypes.