Distal esophageal spasm.

A 42-year-old man presented to the Center for Voice and Swallowing with symptoms of intermittent dysphagia and substernal chest pain. Cardiac causes of the chest pain had been excluded prior to consultation. Transnasal esophagoscopy revealed intermittent nonperistaltic spasms (figure 1, A). Videofluoroscopy showed the typical corkscrew appearance of the esophagus (figure 1, B). Esophageal manometry demonstrated high-amplitude, nonperistaltic, simultaneous contractions limited to the distal two-thirds of the esophagus (figure 2).

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Distal esophageal spasm (formerly known as diffuse esophageal spasm) affects only the smooth-muscle portion of the esophagus. It is diagnosed on esophageal manometry by the presence of simultaneous, nonperistaltic esophageal contractions in 20% or more of wet swallows. Treatment recommendations, which are based only on small studies, include proton-pump inhibitors, nitrates, tricyclic anti-depressants, calcium channel blockers, and serotonin reuptake inhibitors. Distal esophageal spasm may also respond to botulinum toxin injections, dilation, or myotomy.

Suggested reading

Sperandio M, Tutuian R, Gideon RM, et al. Diffuse esophageal spasm: Not diffuse but distal esophageal spasm (DES). Dig Dis Sci 2003;48(7):1380-4.

Tutuian R, Castell DO. Esophageal motility disorders (distal esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter): Modern management. Curr Treat Options Gastroenterol 2006;9(4):283-94.

From the Center for Voice and Swallowing, University of California-Davis, Sacramento.