Are there specific radiographic features of diffuse esophageal spasm ?
A.G. Little, P.O. Bandt (Las Vegas)
It is necessary to understand that there is controversy regarding the definition of diffuse esophageal spasm (DES). In the older literature, DES was used to signify any non-specific motor abnormality of the esophagus identified either radiologically or by manometry. More recently, DES has come to be regarded as a specific motor abnormality which is characterized by the frequent, greater than 10 p. cent, occurrence of simultaneous esophageal contractions with the requirement that occasional swallows induce a normal peristaltic sequence, thus distinguishing this disorder from achalasia . High pressure or prolonged duration contractions may be present but are not required for the diagnosis. Finally, it is necessary that the patient have
symptoms of chest pain or dysphagia or both. Manometric abnormalities in the absence of symptoms do not constitute a clinical abnormality.
Regardless of the definition of DES which one accepts, it has been shown that there are no truly specific radiographic features. Figure 1 shows the type of radiographic esophageal appearances which have been identified in patients with DES. Figure 1A shows the presence of multiple simultaneous, so-call tertiary, contractions. Figure IB shows a more pronounced version of tertiary contractions with actual segmentation, producing a corkscrew or rosary bead appearance.
In an investigation focusing on patients with tertiary contractions detected on routine gastrointestinal X-ray examinations, the majority had identifiable symptoms but seven of 16 patients had no symptoms suggestive of DES, neither dysphagia nor chest pain . In fact, the appearance of the esophagograms could not be used to distinguish symptomatic from asymptomatic patients. This documents that the X-ray findings of tertiary contractions, even when the appearance is dramatic, are not identified only in patients with DES but also occur in asymptomatic persons. This has been shown to be true in many reports [3, 4], and is particularly true in those over the age of 60 who are more likely to have simultaneous contractions than those of a younger age .
The other perspective is to ask whether all DES patients have consistent radiologic abnormalities. In one clinical study, it was shown that of 12 symptomatic patients with manometric changes compatible with DES, including the presence of repetitive and simultaneous contractions, eight or 67 p. cent had completely normal radiologic findings . This observation, that only about one third of DES patients have abnormal esophagograms has been confirmed repeatedly [3, 4].
In conclusion, it is clear that normal, particularly elderly, patients can have tertiary contractions identified on their barium swallow X-ray, showing that these abnormalities can occur in asymptomatic patients as well as those DES. Conversely, only about one third of DES patients will actually have these radiologic abnormalities present during a radiologic investigation.