(See also Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus... read more .)
Abnormalities in esophageal motility correlate poorly with patient symptoms; similar abnormalities may cause different or no symptoms in different people. Furthermore, neither symptoms nor abnormal contractions are definitively associated with histopathologic abnormalities of the esophagus.
Symptoms and Signs of Diffuse Esophageal Spasm
Sometimes, diffuse esophageal spasm is asymptomatic and is found incidentally.
When symptomatic, diffuse esophageal spasm typically causes substernal chest pain with dysphagia Dysphagia Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia should not be confused with globus sensation... read more for both liquids and solids. Very hot or cold liquids may aggravate the pain. Over many years, this disorder rarely evolves into achalasia Achalasia Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more (with impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing).
Esophageal spasms can cause severe pain without dysphagia. This pain is often described as a substernal squeezing pain and may occur in association with exercise. Such pain may be similar to angina pectoris Angina Pectoris Angina pectoris is a clinical syndrome of precordial discomfort or pressure due to transient myocardial ischemia without infarction. It is typically precipitated by exertion or psychologic stress... read more , and patients often present to the emergency department concerned they are having a heart attack.
Diagnosis of Diffuse Esophageal Spasm
Coronary ischemia ruled out
Alternative diagnoses include coronary ischemia, which always needs to be excluded by appropriate testing (eg, ECG, cardiac markers, stress testing—see diagnosis of acute coronary syndromes Diagnosis Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more ). Definitive confirmation of an esophageal origin for symptoms is difficult.
Barium swallow may show poor progression of a bolus and disordered, simultaneous contractions or tertiary contractions. Severe spasms may mimic the radiographic appearance of diverticula but vary in size and position. Typically, barium swallow is done before manometry because it can be used to find other causes of symptoms and is less invasive.
Esophageal manometry Manometry Manometry is measurement of pressure within various parts of the gastrointestinal tract. It is done by passing a catheter containing solid-state or liquid-filled pressure transducers through... read more provides the most specific description of the spasms. At least 20% of test swallows must have a short distal latency (< 4.5 seconds) to meet manometric criteria for diffuse esophageal spasm. However, spasms may not occur during testing.
Esophageal scintigraphy and provocative tests with drugs (eg, edrophonium chloride 10 mg IV) have not proved helpful.
Treatment of Diffuse Esophageal Spasm
Calcium channel blockers
Botulinum toxin injection
Sometimes surgical or endoscopic myotomy
Esophageal spasms are often difficult to treat, and controlled studies of treatment methods are lacking. Anticholinergics, tricyclic antidepressants, nitroglycerin, and long-acting nitrates have had limited success. Calcium channel blockers given orally (eg, verapamil 80 mg 3 times a day, nifedipine 10 mg 3 times a day) may be useful.
Rarely, a trial of injecting botulinum toxin type A into the esophagus and/or lower esophageal sphincter is done.
Medical management is usually sufficient, but surgical or peroral endoscopic myotomy along the full length of the esophagus has been tried in severe cases.
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