What is the role of endoscopy in the investigation of DES ?
H. W. Boyce (Tampa)
Endoscopy is not expected to have a diagnostic or positive confirmatory role in the evaluation of esophageal motility disorders including DES (diffuse esophageal spasm). The etiology and pathophysiology of these disorders is poorly understood and is not discoverable by endoscopy. Therefore, the role of endoscopy is to search for conditions that either may simulate or provoke true idiopathic disorders of motility.
Figure 1. A and B. These endoscopic views of the mid esophagus in a patient with DES reveal simultaneous contractions of the esophageal wall. These contractions are occurring several centimeters distal to the endoscope and are not related to normal peristalsis in this patient.
Figure 1. C and D. The contractions increase to further diminish lumen diameter, at times to the point of total lumen occlusion that can last for several seconds. The mucosa of the esophagus usually is normal as it was in this patient. Esophageal contractions with identical morphological features may be seen in patients who have no symptoms or manometric changes of DES.
The classic example of endoscopy use in neuromotor disorders is to investigate for so called «pseudoachalasia». Since DES also may be secondary in some persons, endoscopy can be helpful. The demonstration of a manometric pattern similar to DES may be impertinent or coincidental to the presence of another disorder that is causing the patient's chest pain. The role of endoscopy then is to exclude the conditions that may cause symptoms similar to DES and to detect the rare case in which DES is precipitaded by acid reflux.
On rare occasion, severe segmental esophageal spasm or prolonged tertiary contractions may be noted during endoscopy. However, as often as not that particular patient has no pain syndrome, that would suggest this finding is of significance. Neither the observation of tertiary contractions nor the dramatic appearances presented by the curling or corkscrew pattern seen during endoscopy can be expected to be of help in the patient's management.
Rarely one will encounter a patient with a syndrome and manometric pattern of DES that can be shown to have significant gastroesophageal acid reflux or acid sensitivity by acid perfusion testing that correlates with the manometric abnormality and the patient's symptoms. Endoscopy only is helpful if findings such as reflux esophagitis, a patulous LES and a hiatial hernia suggest reflux as a possible contributor to the process.
The chest pain, odynophagia, dysphagia, and perhaps the motor abnormalities of DES may be simulated in persons with drug-induced esophageal disease and infectious esophagitis such as those of monillal and viral etiology.
For DES, endoscopy is of value more to exclude alternative causes for symptoms of DES rather than to confirm DES — which it cannot do.