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

• 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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