What is the incidence of intermittent occurrence of simultaneous contractions ?

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 intermittent peristalsis, repetitive or 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 [1,2].

The type of anomaly found changes with the equipment used, the peristaltic waves being much greater in amplitude with a low compliance system, or with micro-transducers in situ, whence the differences in description in the literature (table 1).

The only sign found by every author is an anomaly of propagation of the peristaltic waves, but this proportion varies from one patient to another. It is at least 10 p. cent after liquid swallows (this is a diagnostic criterion, since a lesser proportion may be physiologic). If studies are made with dry swallows, the proportion must be at least 30 p. cent [3,4] to confirm the diagnosis.

However, a study using dry swallows may give rise to errors in diagnosis since there exist healthy volunteers exhibiting 80 to 100 p. cent of non-propagated waves after dry swallows [1],

Richter reports a mean incidence of around 40 p. cent, varying according to the patients from 20 to 90 p. cent, in a series of 95 patients exhibiting such disorders.

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 Increased amplitude duration		Anomalies of LES
	1958	Creamer	-	+	+	-	+	+	-
	1964	Roth	+	+	+	-	-	+	-
	1966	Craddock	-	+	+	-	+	-	-
	1967	Gillies	-	+	+	+	-	+	-
	1970	Bennett	-	+	+	+	+	-	-
	1973	Orlando	-	+	+	+	+	-	+
	1974	DiMarino	+	+	+	-	+	-	+
	1977	Mellow	+	+	+	-	+	+	-
	1977	Swamy	-	+	+	+	+	-	-
	1979	Vantrappen	+	+	+	-	+	+	+
	1981	Kaye	+	+	+	-	+	+	+
	1982	Davies	+	+	+	+	+	+	+
	1982	Patterson	+	+	-	-	+	-	-

In our own experience, based on 18 patients showing this disorder and observed during the last year, the proportion of non-propagated waves is not very different, being equal to 36 p. cent with extremes of 12 and 57 p. cent.

Finally, although the presence of non-propagated waves is essential to the diagnosis, it is not enough in itself since such anomalies may be seen in reflux pathology [5, 6], neuropathies, the collagen disorders and pseudo-obstructions.

References

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

2. Gelfand DW (1988) Motility Disorders. In: The Esophagus: Medical and Surgical Management. Hill LD et al Eds, WB Saunders, Philadelphia pp 180-192.

3. Di Marino AJ, Cohen S (1974) Characteristics of lower esophageal sphincter function in symptomatic diffuse esophageal spasm Gastroenterology 66 : 1-6.

4. Mellow MH (1977) Symptomatic diffuse esophageal spasm manometric follow-up and response to cholinergic stimulation and cholinesterase inhibition Gastroenterology 73 : 237-240.

5. Swamy N (1977) Esophageal spasm and manometric response to nitroglycerin and long acting nitrates Gastroenterology 72 : 23-27.

6. Ahtaridis A, Snape WJ, Cohen S (1979) Clinical and manometric findings in benign peptic strictures of the esophagus Dig Dis Sci 24 : 858-861.