Diagnosis

Esophageal spasm

Etiology

Cause [iph]

• Unknown

• Possible explanations:

  • Neurogenic: Imbalance between the inhibitory and excitatory neural pathways

  • Muscular: Hypertrophy or hyperplasia in the distal part of the esophagus

  • Biochemical: Increased release of acetylcholine

  • Reflux: Exposure to acid can also result in esophageal spasms

Pathophysiology [iph]

1. Peristalsis: coordinated contractions resulting in the transport of food/fluids from the mouth to the stomach in ten seconds

2. Disruption of a coordinated peristaltic wave through the esophageal wall

   Segments of the esophagus contract independently of each other simultaneously

3. Improper propagation of the food bolus --> obstruction --> dysphagia

Risk factors [iph]

• High body mass index

Complications [iph]

• Esophageal perforation

Epidemiology

Incidence per 100.000 [kad]

Approach

• ECG

• Barium enema

• Gastroscopy

• Esophageal manometry [ucv]

  1. Simultaneous contractions during more than 20% of wet swallows

  2. Intermittent normal peristalsis (necessary for diagnosis)

  3. Repetitive contractions with more than three peaks

  4. Prolonged duration contractions lasting more than 6 seconds with retrograde contractions

  5. Isolated incomplete LES relaxation with residual pressure greater than 8 mmHg

Treatment

The goal is to relieve symptoms rather than normalize manometric findings. 

1. Medications: [iph]

   • Reflux-like symptoms --> Proton Pump Inhibitors

   • Nitrates and Calcium-channel blockers (Smooth Muscle Relaxants)

   • Visceral analgesics (tricyclic agents or SSRI)

2. Esophageal treatment: [iph]

   • Botulinum toxin injection (Smooth Muscle Relaxant)

   • Pneumatic dilation

   • Myotomy (extend through the lower esophageal sphincter)

3. Surgery:

   • Myotomy

   • Concomitant fundoplication

Differential diagnoses

Achalasia, Angina pectoris, Chagas disease, Esophageal cancer, Esophageal diverticula, Esophageal perforation, Esophageal stricture, Esophagitis, Gastroesophageal reflux disease, Myocardial infarction, Scleroderma