What is the extent of esophageal body involvement in diffuse esophageal spasm ?
H.J. Stein, T.R. DeMeester, R.R. Klingman (Omaha)
The classic manometric finding in patients with diffuse esophageal spasm is an increased frequency of simultaneous contractions at various levels of the esophagus following wet swallows while retaining some degree of normal peristalsis.
In our laboratory, manometry of the esophageal body is performed in a standardized way with five pressure transducers. The proximal transducer is located 1 cm below the well defined upper esophageal sphincter with the distal openings trailing at 5 cm intervals over the whole length of the esophagus. Wave progression is calculated as the delay between the peak of contractions at the various levels.
A wave is considered simultaneous when the delay between two peaks is shorter than 0.25 seconds, i.e., the speed of peristalsis is greater than 20 cm/second. Wave progression between channels and the incidence of simultaneous waves is displayed graphically against a background of normal values obtained in 50 healthy asymptomatic volunteers (figures 1 and 2).
Figure 1. Computer generated plot of wave progression throughout the esophageal body. The calculation of wave progression is based on the mean time of peak pressures following ten wet swallows at the five levels of the esophageal body. Normal wave progression plots within the dotted lines.
This technique allows determining whether simultaneous contractions occur over the entire length of the esophagus, the distal part, or are confined to a segment of the esophagus. In our experience, simultaneous contractions rarely occur in the proximal segment of the esophagus, i.e., the striated muscle. The distal half or two-thirds of the esophagus, i.e., the smooth muscle portion of the esophagus, is most frequently involved.
Segmental esophageal spasm, i.e., simultaneous contractions between two adjacent segments of the esophagus with normal wave progression proximal and distal to the involved segment, is less common, but may also be the cause of dysphagia and/or chest pain.
Figure 2. Computer generated plot of the incidence of simultaneous pressure peaks between recording levels following ten wet swallows.