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OESO©2015
 
Volume: Primary Motility Disorders of the Esophagus
Chapter: Diffuse esophageal spasms (Corkscrew esophagus)
 

What are the different clinical features of diffuse esophageal spasm ?

R.E. Clouse (Washington)

Any review of the literature on diffuse esophageal spasm (DES) must take into consideration the variable criteria used in diagnosing this disorder. Undoubtedly, only some patients given this manometric diagnosis have corkscrew esophagus on barium radiographs. Nevertheless, despite the variability of manometric features, most authors similarly describe the symptoms of patients given the diagnosis of DES.

Patients with DES manifesting as severe manometric and radiographic abnormalities not infrequently present after age 50 [1]. However, patients with the typical clinical syndrome and with similar but possibly less severe manometric findings may often present at a younger age. Thus, recent reports of subjects with the variety of contraction abnormalities conclude that the mean age of presentation approximates 50 years [2, 3]. Also, there may be a female predilection to this syndrome that had not been previously appreciated.

Hallmark symptoms are chest pain and dysphagia. Most reports of this syndrome have indicated that these symptoms are frequent but intermittent [1-4], yet the precise nature of the symptoms has rarely been described in large series of patients. In our review of 75 subjects with DES or similar but milder manometric derangements, we found that dysphagia for liquids, dysphagia for solids, and chest pain were each reported by 70-80 p. cent of subjects with the severe manometric features typical of esophageal spasm [2]. Chest pain was reported at a similarly high rate (80 %) in patients with milder manometric abnormalities, but dysphagia fell in frequency to 30-50 p. cent. Thus, the severity of contraction wave abnormalities seen in esophageal spasm may correlate more directly with dysphagia than with chest pain. The presence of simultaneous contraction waves has been thought by some authors to be an important requisite for the manometric diagnosis of esophageal spasm [5]. This manometric finding is strongly associated with disrupted bolus transit on X-ray studies. However, correlation of this manometric finding with symptoms has not yet been reported.

The chest pain seen in esophageal spasm is generally retrosternal. We noted in the previously mentioned study [2] that nearly 3/4 of those subjects with chest discomfort described a mid or lower retrosternal location (table 1). In contrast, dysphagia was often sensed in the mid and cervical esophageal regions. These data are consistent with experimental studies showing that balloon distention of the mid and distal esophagus (areas of greatest manometric and radiographic abnormality in DES) will produce cervical symptoms in more than 1/3 of cases [6].

fable 1. Location of symptoms in patients with DES and related disorders

Symptom

Reported retrosternal location (%)

Other chest

Distal

Middle

Upper, suprasternal

location

Chest pain

35

39

4

22

Dysphagia

21

33

45

0

Data adapted from reference [2].

A variety of other clinical observations have been made : symptoms reported in DES are often vague with considerable daily variation in severity. Regurgitation of liquid or solid boluses into the mouth may occur, but this symptom is more commonly encountered in achalasia. A dull pain that persists between severe

episodes is noted by many patients and this may help differentiate DES from cardiac angina. A variety of other discomforts or sensations are also often reported by patients with this syndrome, e.g., the sensation that food passes peculiarly through the retrosternal region. A « gurgling » feeling or heartburn sensation may suggest gastroesophageal reflux, but pH monitoring studies can confirm that such symptoms are not uniformly associated with acid reflux events and may be directly related to the motor disorder. Some patients describe odynophagia, although this is not a frequent complaint.

References

1. Kramer P (1970) Diffuse esophageal spasm. Mod Treat 7 : 1151-1162.

2. Reidel WL, Clouse RE (1985) Variations in clinical presentation of patients with esophageal contraction abnormalities. Dig Dis Sci 30: 1065-1071.

3. Clouse RE, Staiano A (1983) Contraction abnormalities of the esophageal body in patients referred for manometry : a new approach to manometric classification. Dig Dis Sci 28 : 784-791.

4. Fleshier B (1967) Diffuse esophageal spasm. Gastroenterology 52 : 559-564.

5. Richter JE, Castell DO (1984) Diffuse esophageal spasm : a reappraisal. Ann Intern Med 100 : 242-245.

6. Kramer P, Hollander W (1955) Comparison of experimental esophageal pain with clinical pain of angina pectoris and esophageal disease. Gastroenterology 29: 719-743.


Publication date: May 1991 OESO©2015