Diffuse Esophageal Spasms (DES)

Diffuse Oesophageal Spasm, also called as "Prinzmetal Angina of the GI tract" is characterized by oesophageal contractions that are uncoordinated, simultaneous, or rapidly propagated. Usually, several segments of the esophagus contract simultaneously, preventing the propagation of the food bolus. 

Several patients are discharged from ED with a diagnosis of Non-Cardiac Chest pain or MSK pain when the ACS work up turns out to be negative. However,  Esphageal Spasm is not a ED based diagnosis. It often requires a trial of medications such Nitrates/CCBs or studies such as Manometry or Barium Swallow to reach a definitive diagnosis. Regardless, it is important for Emergency Physicians to be aware of this condition to arrange appropriate follow with Gastroenterologists. 

Symptoms:

• Non-Exertional Retrosternal Chest Pain which frequently radiates to the back, and can be more severe than angina (May sound like dissection, pancreatitis, GERD, ACS)
• Globus (ie, the sensation that an object is trapped in the throat)
• Dysphagia, which is more consistent and reproducible during investigative studies
• Regurgitation and Heartburn 

The spasms of the oesophageal muscles can lead to a feeling of food sticking, food obstructing, regurgitation, and chest pain. Symptoms may be worse with cold foods or drinks, but may improve with warm liquids.


Diagnosis:

It is reasonable to rule out ACS with ECGs/Troponins even when there is slightest of concern. Other helpful investigation are:

• Bedside ECHO (Cardiac Contractility, RWMAs, Tamponade, Dilated Right heart, PTx)
• CXR (Pneumonia/PTx, Dilated mediastinum)
• Amylase (Pancreatitis)

The diagnostic modalities of choice for DES are barium swallow and esophageal manometry. Diffuse esophageal spasm has a characteristic appearance of multiple simultaneous contractions causing a corkscrew appearance with segmentation. It is important to remember that Barium Swallow will show this typical corkscrew pattern only if done during an episode of spasm. 

Treatment:

• Calcium channel blockers and nitrates are first-line therapy. Other Treatment options: Sildenafil, Botulinum toxin, Diltiazem
• Surgical Treatment - Myotomy/ Esophagectomy

Author:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

                    

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