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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Sunday, March 12, 2017

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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