Pain, often pseudoanginal, may be the only symptom
H.J. Stein, T.R. DeMeester (Omaha)
Dysphagia for both liquids and solids and chest pain are the classic clinical features associated with diffuse esophageal spasm. The symptomatology of diffuse esophageal spasm differs from classic achalasia in that it produces a lesser degree and more intermittent dysphagia, causes more chest pain, and has less effect on the patient's general condition. In our experience, chest pain as an isolated symptom occurs in only 20 p. cent of patients with documented diffuse esophageal spasm.
Chest pain in patients with diffuse esophageal spasm usually occurs intermittently and may or may not be related to food ingestion. Many patients report an increase in the frequency and severity of chest pain episodes when under emotional or psychological stress. The character of the pain is variable and ranges from sharp or colicky, lasting only a few seconds or minutes, to a dull persistent pressure lasting for hours. The pain is usually located sub-sternally, may radiate into the neck, shoulders, arms and back, and may be relieved by nitrates or calcium channel blockers, thus mimicking « cardiac » chest pain.
Figure 1. Incidence of patients with spontaneous chest pain episodes during 24-hour ambulatory esophageal motility monitoring in 78 patients. NEMD : nonspecific esophageal motor disorder. NCE : nutcracker esophagus. DES : diffuse esophageal spasm.
Figure 2. Ambulatory manometry record of a patient with diffuse esophageal spasm who experienced a spontaneous chest pain episode during the monitoring period. The chest pain episode was associated with a prelude of high amplitude, simultaneous, and repetitive contractions.
A differentiation of « esophageal » chest pain on a symptomatic basis is therefore not possible : often the patients have a history of frequent visits to emergency rooms and evaluations for suspected myocardial infarction, including coronary angiography, prior to the diagnosis of the esophageal motor abnormality. An esophageal motor disorder as the cause of chest pain should be suspected in all patients with substernal chest pain in whom a cardiac cause of the symptoms has been excluded by coronary angiography.
The new technology of 24-hour esophageal motility monitoring has changed the diagnostic approach to these patients, since it allows direct correlation of esophageal motor activity with spontaneous symptoms. We have recently utilized this technique
in 78 symptomatic patients, 20 of whom had spontaneous chest pain episodes occurring during the monitoring period (figure 1). Spontaneous chest pain episodes were associated with a burst of simultaneous and repetitive contractions (figure 2). This occurred in 75 p. cent of patients with primary diffuse esophageal spasm (figure 3).
In the majority of patients without an underlying esophageal motor abnormality, there was no change in the motility pattern preceding and during the pain episodes.
These data suggest that the esophagus is a frequent cause of non-cardiac chest pain in patients with normal coronary arteries, particularly in those with a documented primary diffuse esophageal spasm [3, 4, 5].
Figure 3. Incidence of abnormal esophageal motor function associated with spontaneous chest pain episodes in patients with and without underlying esophageal motor disorders.