What is the cause of the exacerbations in the course of this disorder ?
J-Y. Touchais, Ph. Ducrotte, Ph. Denis (Rouen)
Esophageal chest pain and/or dysphagia are the usual clinical manifestations of exacerbations of symptomatic diffuse esophageal spasm (DES). The reasons for such exacerbations remain poorly understood.
In DES, some patients report that swallowing, especially of cold or very hot liquids, induces chest pain and/or dysphagia. However, the study of human esophageal responses induced by cold liquids failed to demonstrate high-amplitude, repetitive and prolonged contractions, but showed a temporary suppression of esophageal motor activity even during the onset of chest pain . Nevertheless, swallowing may play a part and food ingestion (bread) elicits more simultaneous contractions than a water swallow . The possible role of food ingestion seems more important in DES patients with dysphagia than in patients with noncardiac chest pain .
The effects of stress are more documented. Stacher has shown that simultaneous esophageal contractions may be induced by noxious acoustic stimuli . More recently, Anderson et al. have observed a significant increase in contraction amplitudes in response to laboratory stressors (loud noises, difficult cognitive problems), both in patients with nutcracker esophagus and in healthy volunteers .
The effect of stress may be related to the increase in behavioral display of anxiety. The relation between emotional distress and changes in esophageal motility has been recognized for over a hundred years. More recently, Clouse and Lustman gave a structured psychiatric interview to 50 patients referred for esophageal manometry : a psychiatric diagnosis was made in 21 of 25 patients with motility abnormalities in the distal esophagus. In contrast, a psychiatric diagnosis was made in only 4 of 13 patients with normal manometric findings. The commonest psychiatric diagnoses were somatization disorder, anxiety disorder and depression . The relationship between dysmotility and anxiety could explain the symptomatic efficacy of low-dose trazodone for esophageal contraction abnormalities .
Similar effects of stress and similar psychological profiles have been found in patients with DES and in those with irritable bowel syndrome (IBS). These data suggest that DES and IBS are two conditions which may represent a spectrum of one disease, the irritable gut . Such a disease could affect subjects with a particular psychological profile, some dysfunction of digestive smooth muscle and a decreased pain threshold to digestive distension .
6. Clouse RE, Lustman PJ, Eckert TC, Ferney DM, Griffith LS (1987) Low-dose Trazodone for symptomatic patients with esophageal contraction abnormalities. A double-blind, placebo-controlled trial. Gastroenterology 92 : 1027-1036.