Gastrointestinal | Diffuse Esophageal Spasm

Hi everyone, welcome back to the Med Bulletin Step 2 and 3 podcast. In today's episode, we cover the topic of diffuse esophageal spasm, found under the gastrointestinal section at MedBullets.com. Let's begin with a clinical snapshot. A 49-year-old woman with depression and anxiety presents to the emergency room for chest pain. She reports that she was feeling well, apart from intermittent difficulty swallowing. After her smoothie today, she experienced a cute onset of retro-sternal chest pain that radiated to her neck. She is worried that she is having a heart attack. Let's continue with an introduction to diffuse esophageal spasm. Clinically this is defined as non-perry-stelta contractions of the esophagus that are simultaneous or uncordenated. Conditions that are associated include gastroesophageal reflex disease, depression and anxiety, and neuromuscular or neurodegenerative disorders. In terms of the epidemiology, remember that this is likely underdiagnosed due to vague symptoms. Demographically, this is rare in children and more common in women. With regards to the pathogenesis, the causes are unclear, but it is often precipitated by ingestion of hot or cold liquids and it is possibly due to an aberrant neurological signaling. Moving on to the presentation. Extractions include chest pain which is non-exertional and may radiate to the arm, back, neck or jaw. There may also be dysphasia and aglobic sensation. On exam, there are no specific findings. In terms of further imaging, an upper gastrointestinal barium swallow may demonstrate a cork screw or rosary beta-sophagus only during a spasm, but this is not specific for diffuse esophageal spasm. In terms of further studies, the diagnostic approach can be difficult as this is difficult to distinguish from cardiac chest pain and cardiac workups such as electrocardiogram, stress test, and even coronary angiography is often indicated and normal. Other studies may include esophageal manometry which can be diagnostic. This demonstrates normal lower esophageal sphincter and normal amplitude with simultaneous contractions after a swallow. And endoscopy is typically normal. In terms of the differential, make sure to think about acoolagia, with distinguishing factors being that there will be increased lower esophageal sphincter function. Also think about a nutcracker esophagus. With distinguishing factors being that this will demonstrate coordinated but high amplitude contractions. And also think about angina and acute coronary syndrome. With distinguishing factors being that there will be cardiac wrist factors, elevated cardiac enzymes, and ST changes on EKG. In terms of treatment, first line options include calcium channel blockers and nitrates. This helps to reduce the severity of spasms. Another option is proton pump inhibitors. This helps to treat associated reflex. And another option is tricyclic antidepressants. This helps to treat associated mood disorders. Non-options include endoscopic injection of botulinum toxin and myotomy. This is indicated for severe and incapacitating symptoms refractory to other treatments. And lastly, complications related to defuse esophageal sphincter include a lack of response to treatment. Now that we've discussed the major point relating to defuse esophageal sphincter, let's walk through a question to apply what we've learned and get a sense of how the topic might be tested. For this question, consider the following clinical scenario. A 34-year-old woman presents to the emergency room with chest pain. She has a sensation of something being stuck in her chest, and this is the third episode in the last month. The prior two incidents occurred at the gym while she was drinking a sports drink and resolved after resting for 3-4 minutes. This episode started after she received a news that her father had a heart attack at age 69. This episode lasted for 15 minutes. The patient also notes several months of intermittent difficulty swallowing, but denies palpitations, diaphoresis, or shortness of breath. She has a past medical history of obesity and long-standing gastroesophageal reflex disease for which she takes homepursual daily. The patient has a family history of sclerodermine her mother. She does not smoke cigarettes, she drinks alcohol socially, and does not use drugs. Her temperature is 98.4 degrees Fahrenheit or 36.8 degrees Celsius. Blood pressure is 143/82. Pulse is 89 beats per minute, and respirations are 16 breaths per minute. The patient appears mildly uncomfortable, but is in no acute distress. There is a normal S1 and S2 on cardiac oscillation, without murmurs or gallops. Her lungs are clear bilaterally. Each of the following is the most appropriate confirmatory test, and the answer choices are choice one, barium swallow, choice two, electrocardiogram, choice three, and doscopy. Choice four is soffogilmanometry, or choice five, troponin. The best answer to this question is choice four is soffogilmanometry. This young woman presenting with intermittent dysphagia, several episodes of central chest pain after drinking cold liquids and emotional stress, and no significant vital sign abnormal malities, most likely has diffusesophageal spasm. The diagnostic test of choice for DES is a soffogilmanometry. In DES, patients experience chest pain and dysphagia that are triggered by hot or cold and justions or stress. DES is characterized by uncoordinated contractions of the esophagus. Initial workups should rule out cardiac chest pain, but the key confirmatory test for DES is a soffogilmanometry. Because DES is likely due to impairment of inhibitory innervation, testing will show normal amplitude, and often simultaneous uncoordinated esophageal contractions. Nitroclisrin, non-dihydropyridine calcium channel blockers, and tricyclic antidepressants are all initial treatments for DES. Bachelainment toxic injections and myotomy are reserved for refractory cases. Let's also discuss whether other choices are incorrect. Choice one. Barium swallow can be useful for DES though it is not the best confirmatory test or most specific test. The postbarium swallow radiograph would show a characteristic corkscrew pattern from uncoordinated contractions, but this would only be apparent during a DES episode. Barium swallows also potentially helpful in ruling out a galasia, a disorder of increased LES tone. Choices two and five. An electrocardiogram and orterpone should be performed in patients presenting with chest pain to rule out cardiac ideologies. Cardiac chest pain typically presents as chest pain with the dull, crushing quality, external in location, worse with exertion, and improved with rest or nitroclisrin. Ischemic causes of chest pain are less likely in younger patients without risk factors. Choice three. And doscopy is a helpful tool for many esophageal disorders such as baritisophagus and infectious esophageitis. Baritisophagus would present with evidence of dysplasia on endoscopy and presents in patients with the long history of curd. It would not cause chest pain associated with drinking cold beverages or emotional stress. DES is a dysmotility disorder and would not produce any endoscopic findings. Finally, a bullet summary. The most appropriate confirmatory test for diffuse esophageal spasm is esophageal monometry. That's all for this review about diffuse esophageal spasm. We hope that was helpful. This is the Med Bullets Step Two and Three podcast. A daily audio review session for Med Bullets. The free learning and collaboration community for medical student education. 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