Diffuse Esophageal Spasm

Snapshot

A 50-year-old woman with a history of acid reflux presents to her primary care physician for intermittent non-exertional chest pain. The pain is not associated with exercise or shortness of breath. She also reports that for the past few months, she has experienced the sensation of food stuck in her throat. She had been worried about her heart, and so she recently had an extensive work-up for coronary artery disease with her cardiologist, all of which were negative. Suspicious for an esophageal etiology for her chest pain, her physician orders an upper gastrointestinal barium swallow study, which shows a corkscrew-like esophagus. She is started on a calcium channel blocker.

Introduction

Overview
- diffuse esophageal spasms are non-peristaltic contractions of the esophagus that are simultaneous or uncoordinated
Epidemiology
- incidence
  - likely underdiagnosed due to vague symptoms
- demographs
  - rare in children
  - more common in women
Pathogenesis
- causes are unclear
- often precipitated by ingestion of hot or cold liquids
- possibly due to aberrant neurological signaling
Associated conditions
- gastroesophageal reflux disease
- depression and anxiety
neuromuscular or neurodegenerative disorders

Presentation

Symptoms
- chest pain (non-exertional) that may radiate to arm, back, neck, or jaw
- dysphagia
- globus
Physical exam
no specific findings

Imaging

Upper gastrointestinal barium swallow study
- findings
  - “corkscrew” or “rosary bead esophagus” only during a spasm
not specific to diffuse esophageal spasm

Studies

Diagnostic approach
- can be difficult to distinguish from cardiac chest pain and cardiac work up such as electrocardiogram (EKG), stress test, and even coronary angiography is often indicated
Invasive studies
- endoscopy
  - findings
    - normal
- esophageal manometry
  - indications
    - diagnostic
  - findings
shows normal lower esophageal sphincter and normal-amplitude, simultaneous contracts after a swallow

Differential

Achalasia
- distinguishing factor
  - increased lower esophageal sphincter function
Nutcracker esophagus
- distinguishing factor
  - coordinated but high amplitude contractions
Angina and acute coronary syndrome
- distinguishing factors
  - cardiac risk factors
  - ↑ cardiac enzymes
ST changes on EKG

Treatment

Complications