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

Can diffuse esophageal spasm be asymptomatic ?

G. Cargill( Paris)

The classical symptoms of diffuse spasm are retrosternal thoracic pain, sometimes of anginal nature, and/or dysphagia, as well as tertiary contractions at radiologic examination and, finally, characteristic specific manometric anomalies such as simultaneous esophageal contractions in more than 10 p. cent of wet swallows, normal but intermittent peristalsis, repetitive and at least triphasic contractions, prolonged duration of contractions increased amplitude of contractions, spontaneous contractions, sometimes incomplete relaxation of the lower sphincter and elevated basal pressure [1].

The type of anomaly found changes with the equipment used, the peristaltic waves being much greater in amplitude with a system of low compliance or with micro transducers in situ. Hence the differences in description in the literature (table I).

The dominant symptoms are retrosternal pain which may radiate to the back and shoulders, sometimes mimicking angina and sometimes relieved by nitro-compounds, and dysphagia. These symptoms are sometimes occasional, intermittent and moderate, sometimes severe in others. The pain is not necessarily related to swallowing but may be influenced by food intake, notably by hot or iced fluids. The pain may waken the patient and is often increased by stress.

However, the signs described above are alarm signs requiring investigations, including manometry, leading to the diagnosis. There is no reason to think that

Table 1. Different descriptions of the disorder of diffuse spasm in the literature.

Criteria of diffuse spasm of the esophagus (after Richter)[l]

Year

Author

Intermittent peristalsis

Simultaneous contractions

Repetitive waves

Spontaneous motility

Increased amplitude

Increased duration

Anomalies of LES

1958

Creamer

-

+

+

-

+

+

-

1964

Roth

+

+

+

-

-

+

-

1966

Craddock

-

+

+

-

+

-

-

1967

Gillies

-

+

+

+

-

+

-

1970

Bennett

-

+

+

+

+

-

-

1973

Orlando

-

+

+

+

+

-

+

1974

Di Marino

+

+

+

-

+

-

+

1977

Mellow

+

+

+

-

+

+

-

1977

Swamy

-

+

+

+

+

-

-

1979

Vantrappen

+

+

+

-

+

+

+

1981

Kaye

+

+

+

-

+

+

+

1982

Davies

+

+

+

+

+

+

+

1982

Patterson

+

+

-

-

+

-

-

there may not be certain silent, asymptomatic forms. Gelfand [2] cites the existence of such forms without reporting their incidence.

To identify the possible incidence of such anomalies, it would be necessary to carry out manometric investigations in a reference population to establish the prevalence of the disease. We ourselves have never found anomalies suggestive of diffuse esophageal spasm in healthy volunteers studied at the termination of pharmacoclinical or pharmacologic studies.

Apart from diffuse spasm discovered during assessment for suggestive symptoms, we have found anomalies suggestive of DES in a patient aged 11 years referred for systematic review, with the picture of an adrenal insufficiency syndrome: alacrimia, associated classically in childhood with sphincteric achalasia. This child did not present any disorder of swallowing clinically ; there was no dysphagia, either for solids or liquids, and no retrosternal pain.

Manometric examination was called for as a routine in the context of assessment of the Addison's disease. The manometric study demonstrated an inferior sphincter of normal tonus at normal level (varying with the tracks from 2 to 3.5 KPa), with relaxation on swallowing not always perfect (varying by 75 to 100 %), and peristaltic waves of increased duration sometimes reaching an amplitude of 40 to 65 KPa.

These waves were non-propagated as much after dry swallows as after moist swallows. They alternated with rare propagated waves and waves showing normal amplitude and propagation (17 % of waves observed on the tracing). When their amplitude was increased, their duration was likewise increased, amply exceeding 6 seconds, sometimes exceeding 10 seconds. All these anomalies combine in a pathology of diffuse spasm capable of developing, in our view, towards an achalasia typical of Addison's disease. Are we entitled to speak of diffuse spasm in cases like this ?

This is uncertain, since the generally accepted definitions of the disorder include pain.

To sum up, diffuse spasm of the esophagus seems to be observable during non-suggestive symptoms, a case discovered during routine investigation being reported here. No arguments can be advanced against the existence of such asymptomatic disorders, such as are reported elsewhere by some authors. However, since the definition of diffuse spasm includes pain, it might perhaps be more logical in such cases to speak of a manometric syndrome of diffuse spasm, so as to indicate the difference from classical diffuse spasm.

References

1. Richter JE (1987) Diffuse esophageal spasm. In : Esophageal motility testing. Castell DO, Richter JE, Dalton CB Eds, Elsevier, New York pp 118-129.

2. Gelfand DW (1988) Motility Discorders. In: The Esophagus: medical and surgical management. Hill LD et al Ed, WB Saunders, Philadelphia pp 180-192.


Publication date: May 1991 OESO©2015