Oesophageal Spasm

Background and Epidemiology

  • There are two main forms of oesophageal spasm:
    • Diffuse oesophageal spasm- where peristaltic contractions are of normal amplitude but are uncoordinated.
    • Hypertensive (or nutcracker) oesophagus- where peristaltic contractions are coordinated but excessive in amplitude.
  • Both are rare as a primary diagnosis (~1 in 100,000 per year).  However, it is thought to be far more common in the general population (e.g. DOS is found in 3-10% of patients who have manometry, particularly in patients >50 years old)

Presentation

  • Non-cardiac chest pain is common (particularly in nutcracker oesophagus)
    • Retrosternal; onset after meals; often radiates to the back; can be severe
    • May mimic cardiac pain e.g. by radiating to the left shoulder
  • Dysphagia and Globus (the sensation of a mass in the throat) are also common (moreso in DOS; rarer in nutcracker oesophagus)
  • Regurgitation, heartburn/dyspepsia
  • Cough and hoarseness can also occur as a result of reflux problems

Investigations

  • If cardiac cause is suspected, urgent ECG and troponins are required.
  • If there is a convincing history of oesophageal disease,
    • Barium swallow
      • may show a ‘corkscrew oesophagus’ picture

Korkenzieher-Ösophagus

  • Manometry
    • >2 uncoorddinated contractions with 10 consecutive wet swallows or >20% simultaneous contractions is usually what is diagnostic of DOS
    • Nutcracker oesophagus is diagnosed by a distal contractile interval of >5000mmHg/s/cm over 10 swallows
      • Severe (or jackhammer oesophagus) cases is that >8000mmHg/s/cm
  • If neither of these tests are positive, consider endoscopy to rule out strictures/webs, stenosis etc
  • If manometry reveals spasm but is not diagnostic for either NO or DOS, USS may help to differentiate.

Management

  • It is important to rule out
    1. Cardiac causes
    2. GORD- trial with a PPI for one month and see if symptoms improve.  Some suggest to do this before investigating with manometry given the epidemiology of motility disorders and GORD, respectively
  • If there is confirmed DOS/NO
    • As well as a PPI, nifedipine (calcium channel blocker) and nitrates can be used
    • Other drugs that can be tried are antidepressants, theophyllines
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