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 pain 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 ingested along with 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 a very important part of the digestive process.
In the absence of such sequenced wave-like contractions, the movement of food from the esophagus to the stomach will be affected.
The diffuse esophageal spasm and the nutcracker esophagus are both subtypes of esophageal spasms and are 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 normal 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 contractions of the esophagus (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 may 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 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 still unknown and it is believed that this condition is idiopathic, medical experts believe that inflammation of the esophagus due to regurgitation of stomach acid into the esophagus can make the individual susceptible to this condition .
Structural abnormalities such as thickening of the smooth muscle in the esophageal wall or malfunction 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 relaxation and contraction of muscles and, therefore, a defect in the nitric oxide pathway can affect the peristalsis process.
With regard to the symptoms of diffuse esophageal spasm, the patient may experience a knot in the throat sensation due to obstruction of food.
The dysphagia or difficulty swallowing is usually a direct result of abnormal esophageal contractions and irregular.
The patient may also suffer from heartburn and chest pain.
As the individual may face many difficulties swallowing food, this may even suffer from loss of appetite.
In the absence of timely medical treatment, esophageal spasms could even become achalasia. This is a medical condition that is characterized by the inability of the esophagus to relax along with the inability 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.
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, which is located retrosternally and radiates to the back.
Patients also complain of dysphagia that is characterized by difficulty swallowing several seconds after starting a swallow, a feeling of food clogging and regurgitation. There is also a globus or knot feeling in the throat, and many patients suffer from heartburn.
The symptoms are intermittent and vary in frequency and intensity. The pain can be caused by particular foods and beverages.
Diagnosis of diffuse spasm
There is no laboratory marker that 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 are suggestive of 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 at the same time, causing an appearance similar to a corkscrew.
Manometry is the best modality to diagnose esophageal spasm. 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 spasm, will have more than 20 percent premature contractions in the topography of esophageal pressure.
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 the lining of your upper gastrointestinal tract and take biopsies (tissue samples) if necessary.
Therefore, it is essential that diagnostic tests are 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.
Modification of the diet can be beneficial in case of patients suffering from acid reflux disease. Since the consumption of 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, which have been shown to be 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 nitric oxide such as isosorbide or sildenafil.
In severe cases, surgery may be recommended for the treatment of a symptomatic diffuse esophageal spasm.
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 for the treatment of this esophageal motility disorder.
If all else fails, a last resort is 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 cases are ruled out, leaving them confused with little relief from their pain. These patients have an increased risk of achalasia.
As in the case of any medical condition, an opportune diagnosis will not only help in the successful management of the symptoms, but also in the prevention of the recurrence of such episodes in the future.