Index
It is an uncoordinated contraction in the esophagus.
The term ” diffuse esophageal spasm ” refers to the sudden and involuntary contraction of the esophageal muscles.
Esophageal spasms present as recurrent chest pain, not cardiac distress, and can be very problematic.
Many patients who come to the hospital are first discarded for chest heart pain, then most investigations stop, and they will be discharged without a follow-up plan.
The esophagus, also commonly known as the food pipe, is a tube that carries food ingested from the mouth to the stomach.
The food is ingested, and the saliva is propelled down from this tube with the help of undulating muscular contractions.
This process is medically known as peristalsis.
These series of coordinated wave-like contractions are essential to propel food from one part of the digestive tract to another. Therefore, it is an integral part of the digestive process.
In the absence of such sequenced wave-like contractions, food movement from the esophagus to the stomach will be affected.
The diffuse esophageal spasm and the nutcracker esophagus are subtypes of esophageal spasms classified into esophageal motility disorders.
Esophageal spasms are abnormal muscle contractions that affect sequential wave-like contractions that facilitate the movement of food ingested from the esophagus into the stomach.
While diffuse esophageal spasm refers to uncoordinated contractions of the esophageal muscles, the nutcracker refers to well-coordinated high-pressure contractions that can take place in the esophagus, regardless of the presence or absence of food in the food pipe.
Diffuse esophageal spasm is a disorder related to movement (motility) of the esophagus and may impair average swallowing ability or cause chest pain in some patients.
Typical symptoms include feelings of suffocation or problems swallowing and discomfort in the chest.
Causes of diffuse spasm
This problem can be caused by simultaneous esophagus contractions (dysmotility).
This is seen mainly in the lower esophagus just above the stomach. In addition, a specialized area of muscle tissue called a lower esophageal sphincter might be too tight, making it difficult for food or liquids to enter the stomach.
The esophageal sphincter muscle is found at the junction of the esophagus and the stomach.
The work of the esophageal sphincter muscle is to act as a one-way valve, allowing food to enter the stomach and prevent it from returning to the esophagus.
Esophageal hypersensitivity may also occur (discomfort experienced with normal esophageal processes due to increased awareness or intense nerve sensitivities).
Although the exact cause of diffuse esophageal spasm is unknown, and it is believed that this condition is idiopathic, medical experts believe that inflammation of the esophagus is due to regurgitation of stomach acid into the esophagus can make the individual susceptible to this condition.
Structural abnormalities such as thickening the smooth muscle in the esophageal wall or malfunctioning of the lower esophageal sphincter muscle may also put one at greater risk of developing this condition.
It is believed that nitric oxide plays a vital role in facilitating the relaxation and contraction of muscles. Therefore, a defect in the nitric oxide pathway can affect the peristalsis process.
About the symptoms of diffuse esophageal spasm, the patient may experience a knot in the throat sensation due to food obstruction.
The dysphagia or difficulty swallowing is usually a direct result of abnormal esophageal contractions and irregularity.
The patient may also suffer from heartburn and chest pain.
As the individual may face many difficulties swallowing food, they may even suffer from losing appetite.
In the absence of timely medical treatment, esophageal spasms could even become achalasia. This is a medical condition characterized by the esophagus’s inability to relax, along with the failure of the lower esophageal sphincter to open up and push food into the stomach.
Therefore, there is a great need to identify the underlying cause and treat esophageal spasms at the earliest.
symptom
Among the symptoms that occur when the patient suffers from diffuse esophageal spasm, the following may be mentioned:
Esophageal spasms occur with non-cardiac chest pain, located in the retrosternal, and radiate to the back.
Patients also complain of dysphagia, characterized by difficulty swallowing several seconds after starting a swallow, a feeling of food clogging, and regurgitation. There is also a global knot in the throat, and many patients suffer from heartburn.
The symptoms are intermittent and vary in frequency and intensity. Particular foods and beverages can cause pain.
Diagnosis of diffuse spasm
No laboratory marker can help in the diagnosis of these conditions.
Eliminating the possibility of other causes of symptoms such as acid reflux disease, other esophageal motility disorders, or narrowing of the esophagus is important to ensure that the correct treatment is initiated.
If the symptoms suggest gastroesophageal reflux, empirical treatment can be started.
If there is no relief, then the tests below should be done:
Barium swallow studies
The thick barium contrast solution is swallowed to see structures of the esophagus by X-rays and, potentially, watch the reflux of stomach contents.
The modality of choice is barium swallowing and esophageal manometry.
A barium swallow will show an esophageal spasm from multiple contractions that appear simultaneously, causing an appearance similar to a corkscrew.
Manometry is the best modality to diagnose esophageal spasms. The variants have characteristic findings.
The nutcracker esophagus is characterized by coordinated contractions in the smooth muscle of the esophagus with excessive amplitude and duration.
Diffuse esophageal spasms will have more than 20 percent premature contractions in the topography of esophageal pressure.
Esophageal manometry
The esophageal manometry measures the esophageal pressures and the swallowing capacity of the patient.
Upper endoscopy or EGD (esophagogastroduodenoscopy).
Since these patients have dysphagia, an endoscopy will be required to rule out structural problems.
This is a procedure whereby a small tube of light is passed through the esophagus, stomach, and first portion of the small intestine.
This test allows the doctor to see your upper gastrointestinal tract lining and take biopsies (tissue samples).
Treatment
Certain medical conditions such as diabetes mellitus, alcoholic neuropathy, amyloidosis, anxiety, scleroderma, and acid reflux disease may increase the risk of distal esophageal spasm.
Therefore, diagnostic tests must be carried out to formulate a diagnosis.
In esophageal manometry, radiographic studies of barium swallowing, ultrasound, and other imaging procedures can be performed to evaluate the condition of the esophagus.
Modifying the diet can benefit patients suffering from acid reflux disease since consuming very hot or cold foods, and drinks can trigger abnormal contractions.
When it comes to drug therapy, doctors usually follow a symptomatic approach.
Medications may be recommended to alleviate the specific symptoms that the patient may be experiencing.
Calcium channel blockers, such as diltiazem, tricyclic antidepressants, and imipramine, effective in small randomized trials, may be recommended.
If the pharmacological therapy is not giving the desired results, there are few treatment options; the botulinum toxin can be injected into the gastroesophageal junction or a drug that contributes with a nitric oxide such as isosorbide or sildenafil.
Surgery may be recommended to treat asymptomatic diffuse esophageal spasms in severe cases.
The prognosis is good if this condition is diagnosed and treated during the early stages.
If treated early, there is a lower chance that such spasms will progress to achalasia.
Difficulty swallowing food, chest pain, heartburn, and a variety of other symptoms that occur due to this condition can be controlled with the help of drug therapy.
Modifying the diet can also help reduce the incidence of such episodes.
In severe cases, surgical procedures such as esophageal dilatation or esophageal myotomy may be required to treat this esophageal motility disorder.
If all else fails, the last resort is an esophagectomy.
Prognosis of diffuse spasm
Mortality is rare, but morbidity is significant and will affect the quality of life with possible psychological problems in development, especially if the diagnosis is not made.
Patients are frequent visitors to the emergency room and are often discharged once cardiac causes are ruled out, leaving them confused with little relief from their pain. These patients have an increased risk of achalasia.
