Diagnosis Of Diffuse Esophageal Spasm Research Articles

High-resolution manometry in the diagnosis of diffuse esophageal spasm: A rare motility disorder

Background: Diffuse esophageal spasm (DOS) is a rare motility disorder. High-resolution manometry (HRM) is used for the diagnosis of DOS in patients confirmed with non-cardiac chest pain and/or dysphagia. The body of the esophagus and the lower esophageal sphincter (LOS) exhibit various motility characteristics that are typical to DOS. The study was conducted to study the HRM patterns in DOS using a 16-channel water perfusion high-resolution esophageal manometer. Aims and Objectives: The objective of the study was to analyze the various motility patterns in DOS with the help of HRM and also to look for those patients who, at the time of the HRM recording, did not reveal overt patterns of motility that is typical to DOS. Materials and Methods: HRM was performed in 13 adult patients (mean age = 61 years) referred as cases of DOS, out of which three had HRM features of DOS. All patients were subjected to HRM following which the results were analyzed. Results: Ten cases had essentially normal HRM findings. The other three patients had a high basal LOS pressure (BLOSP) and elevated distal wave amplitudes. However, all three cases had a normal LOS relaxation pattern. Manometric features of DOS may not be obvious in all referred cases of DOS, and hence, false-negative results are likely. DOS often has high BLOSP along with very high distal wave amplitudes. However, the LOS relaxation during swallows does not get affected. Although the mean age for DOS is 71 years, yet it can also occur in younger adults. Conclusion: Most of the DOS patients may not manifest manometrically at the time when they are actually undergoing the recording, which leaves a number of cases with a normal HRM finding. Thus, it would not be reasonable to rule out DOS in the absence of HRM confirmation.

Thoracoscopic Long Myotomy in the Prone Position to Treat Rapid Esophageal Contractions With Normal Latency

A 56-year-old woman with an 8-year history of dysphagia and chest pain received a diagnosis of diffuse esophageal spasm by esophageal high-resolution manometry (HRM). Approximately 2 years of medical therapy was ineffective, and the patient's symptoms were worsening. Therefore, surgery was considered to be the most optimal treatment for this patient. The right thoracoscopic approach was selected because a long myotomy from the distal to proximal level of the esophagus was needed based on the HRM findings. The operation was performed in the prone position with establishment of pneumothorax. The total length of the myotomy was 16 cm, and the operation was finished within 2 hours. After the operation, the symptoms were considerably improved and no contractions were detected by HRM. The HRM findings before the operation were classified as rapid contractions with normal latency based on the 2012 Chicago classification of esophageal motility. Treatment for patients with rapid esophageal contractions with normal latency has not been previously described; however, treatment for diffuse esophageal spasm was considered to be pertinent to this patient. In conclusion, right thoracoscopic esophageal long myotomy in the prone position with establishment of pneumothorax may be useful when a proximal-level esophagomyotomy is required based on preoperative mapping by HRM.

Diffuse esophageal spasm and detrusor spasm: Combined visceral neuromuscular disorders in a patient with William’s Syndrome

William’s Syndrome is a rare genetic disorder associated with developmental delay, gregarious personality, characteristic facies, multiple medical complications and valvular heart disease. Urologic and gastrointestinal complications including motor abnormalities and diverticulosis of the bladder and colon are commonly present. We present a case of a 37 year old male with William’s Syndrome who originally demonstrated typical bladder and bowel dysfunction associated with the condition, but also later developed severe dysphagia and associated weight loss. An esophagram revealed the presence of three large distal (epiphrenic) esophageal diverticula. These are most often caused by the presence of an underlying esophageal motility disorder. High-resolution esophageal manometry was performed and showed multiple simultaneous contractions and non-propagated contractions with swallowing maneuvers, consistent with the diagnosis of diffuse esophageal spasm (DES). This is the first case of an esophageal motor disorder described in a patient with William’s Syndrome and supports the concept that there is a generalized visceral neuromuscular dysfunction present in these patients.

Chest Pain During Upper Endoscopy

A 75-year-old male patient visited Seoul St. Mary's Hospital for regular check-up after endoscopic resection of the early gastric cancer. He complained of mild and intermittent dysphagia to solids and liquids for 1 year duration. Frequency of dysphagia increased recently. Previously performed upper endoscopies were reported as normal. After insertion of endoscopy, he complained of severe chest pain. The esophageal mucosa appeared normal but there were severe contractions leading to resistance in advancing the scope in the mid esophagus (Fig. 1). Esophagogram showed a corkscrew appearance on the mid and lower part of the esophagus (Fig. 2). Esophageal manometry disclosed the hypercontractile amplitudes of 365 mmHg (Fig. 3). A normal relaxation of the lower esophageal sphincter ruled out achalasia. Cardiac evaluation revealed nonspecific findings. These findings led to the diagnosis of diffuse esophageal spasm (DES), which was responsible for the chest pain. Chest pain subsided with the treatment of proton pump inhibitor, verapamil and isosorbide mononitrate. Figure 1 Upper endoscopy before (A) and after (B) the development of chest pain. Powerful contraction of mid esophagus is observed in the figure 1B. Figure 2 Corkscrew esophagus on barium esophagogram. Figure 3 Esophageal manometry shows multiple spontaneous simultaneous contractions. The amplitudes of these contractions are particularly high. The pain associated with DES are very variable in severity and sometimes can mimic that of angina pectoris.1 Upper endoscopy is firstly recommended to detect structural causes of dysphagia and noncardiac chest pain. In most affected patients, the esophagus retains the ability to propagate normal peristaltic contractions. As endoscopy has substantial limitations in assessing abnormal esophageal motility in DES, the intraluminal manometry is usually needed for the diagnosis of increased pressure of nonperistaltic contractions.2 The presented case showed interestingly endoscopic findings strongly suggestive of DES along with compatible radiographic and manometric findings.

Endoskopische Injektion von Botulinumtoxin A bei einem Patienten mit diffusem Ösophagusspasmus

A 67-year-old man complained of recurrent retrosternal pain for 3 - 5 minutes as the only symptom for 3 - 4 years. Only when dysphagia occurred in the course of the disease was a gastroenterologist consulted. The diagnosis of diffuse esophageal spasm was confirmed by esophageal manometry and radiology. Upper gastrointestinal endoscopy revealed no further pathological findings. 100 units of botulinum toxin were injected in 10 divided doses, into the tubular esophagus, 1 cm apart, beginning at the z-line of the gastroesophageal junction, deeply into the muscular coat of the posterior part of the esophageal wall. This achieved improvement of symptoms as well as esophageal transit time measured by scintigraphy. The symptomatic benefit has now lasted for several months. The treatment of patients with diffuse esophageal spasm with botulinum toxin is a promising therapeutic option, which can be safely performed in such patients. But this regime needs evaluation in controlled prospective clinical studies.

Thoracoscopic management of postoperative esophageal leak

Esophageal perforation is an uncommon problem, but one that is associated with high mortality (9%-36%). 1-3 Treatment consists of aggressive surgical management and broadspectrum antibiotics. Surgical approaches to management of esophageal perforation include primary closure, esophagectomy, use of esophageal T-tube, exclusion-diversion, and mediastinal drainage. Selection of treatment depends on factors such as the cause and duration of perforation, clinical condition of the patient, and the degree of surrounding tissue injury. During the past decade, advances in minimally invasive surgical technology have allowed surgeons to apply thoracoscopic methods to the management of esophageal disease. Thoracoscopic operations have been applied to esophageal myotomy, resection of esophageal diverticulum, excision of esophageal leiomyoma, antireflux operations, and esophagectomy. 4 In this report we used our experience in video-assisted thoracoscopic operations for the management of 2 patients in whom an esophageal perforation developed as a result of a thoracoscopic esophageal operation. Clinical summary. The first patient was a 60-year-old woman who was referred with a 2-year history of severe chest pain and intermittent dysphagia. Upper esophageal endoscopy showed no obstructive lesions. Esophageal manometry revealed high-amplitude contraction in the body of the esophagus consistent with a diagnosis of diffuse esophageal spasm. The patient was treated nonoperatively with calcium-channel blockers and nitrates without success. She was offered surgical treatment consisting of a long esophagomyotomy. The operation was performed through the right side of the chest with 4 thoracoscopic trocars. Intraoperative endoscopy after the myotomy revealed no air leaks (Fig 1). The patient was discharged on postoperative day 4 on a clear liquid diet. On postoperative day 7, the patient returned with shortness of breath and acute chest pain. Gastrograffin contrast study revealed extravasation of contrast material at the midesophageal region. Endoscopy showed a small 3-mm perforation at the middle esophagus. The patient was reexplored thoracoscopically. Intraoperative endoscopy identified the

Esophageal Wall Thickening: A CT Finding in Diffuse Esophageal Spasm

We report three patients with esophageal wall thickening, incidentally found at CT, in whom further evaluation led to the diagnosis of diffuse esophageal spasm (DES). All cases showed smooth, symmetric, circumferential wall thickening of the distal two-thirds of the esophagus with normal periesophageal fat. No lung parenchymal abnormalities suggestive of aspiration were seen. DES, although uncommon, is another benign condition that should be included in the differential diagnosis of esophageal wall thickening detected by CT.

Manometric diagnosis of diffuse esophageal spasm

There are no requirements concerning the amplitude of simultaneous contractions among the present criteria for the manometric diagnosis of diffuse esophageal spasm. The purpose of this investigation was to determine whether the current criteria effectively identify an appropriately homogenous patient population. Sixty consecutive motility tracings that met the criteria for diffuse esophageal spasm were evaluated. A bimodal distribution of the highest simultaneous esophageal contraction for each patient was observed. One group's (N = 29) highest simultaneous esophageal contractile amplitude was < or = 74 mm Hg, the other's (N = 31) highest simultaneous esophageal contractile amplitude was > or = 100 mm Hg. Group 1 had significantly decreased lower esophageal sphincter pressure, lower peristaltic amplitude, more aperistalsis, fewer simultaneous contractions, and fewer complaints of chest pain. These comparisons suggest that consideration be given to the amplitude of simultaneous esophageal contractions in the manometric diagnosis of diffuse esophageal spasm.

Long esophageal myotomy with a fundic patch procedure for treating diffuse esophageal spasm: Report of a case

A diagnosis of diffuse esophageal spasm (DES) based on radiological and manometric studies was made in a 70-year-old man who presented with severe dysphagia, vomiting, and spontaneous chest pain. The manometric studies revealed a simultaneous onset of high amplitude contractions and a hypertensive lower esophageal sphincter (LES) that was well relaxed in response to deglutition, in contrast to the incomplete relaxation seen in achalasia. Because his dysphagia was so severe and did not respond to pneumatic dilatation, the patient was treated by a long esophageal myotomy with a full thickness incision through the LES and mucosa, adding a Thal-Hatafuku procedure. The patient made a good postoperative recovery and has since been eating normally without any further dysphagia or chest pain. Good manometric and radiological results have been obtained in this patient during 5 years of follow-up.

Chest Pain and Dysphagia in Adolescents Caused by Diffuse Esophageal Spasm

Five adolescents, 13–18 years of age, underwent esophageal manometric studies because of chronic symptoms suggestive of esophageal dysfunction. Four of five patients had episodic nonexertional midchest pain; two patients experienced intermittent dysphagia. The manometric findings for these adolescents were consistent with a primary motility disorder known as diffuse esophageal spasm, a condition not previously reported in this age group. This represents approximately 1% of all pediatric patients undergoing esophageal manometry at our institution for the past 5 years. They have been followed for at least 2 years and three have experienced gradual resolution of their symptoms with normalization of manometric findings. Our report emphasizes two main points: (a) Diffuse esophageal spasm may cause chest pain and dysphagia in adolescents; and (b) the clinical history and esophageal manometric findings establish the diagnosis of diffuse esophageal spasm.

Chest pain and dysphagia in adolescents caused by diffuse esophageal spasm.

Five adolescents, 13-18 years of age, underwent esophageal manometric studies because of chronic symptoms suggestive of esophageal dysfunction. Four of five patients had episodic nonexertional midchest pain; two patients experienced intermittent dysphagia. The manometric findings for these adolescents were consistent with a primary motility disorder known as diffuse esophageal spasm, a condition not previously reported in this age group. This represents approximately 1% of all pediatric patients undergoing esophageal manometry at our institution for the past 5 years. They have been followed for at least 2 years and three have experienced gradual resolution of their symptoms with normalization of manometric findings. Our report emphasizes two main points: (a) Diffuse esophageal spasm may cause chest pain and dysphagia in adolescents; and (b) the clinical history and esophageal manometric findings establish the diagnosis of diffuse esophageal spasm.

Diffuse esophageal spasm: a reappraisal.

With the renewed interest in esophageal motility disorders, diffuse esophageal spasm is being diagnosed more frequently. In many clinical settings, however, the term is used as a synonym for noncardiac chest pain. Our review of the literature and broad clinical experience in studying the motility patterns of healthy subjects have helped us better define diffuse esophageal spasm. The diagnosis of diffuse esophageal spasm should be considered only in symptomatic patients showing simultaneous contractions after wet swallows during esophageal motility testing. Simultaneous contractions should occur after at least 10% of swallows and be intermixed with normal peristaltic contractions. Repetitive waves, contractions of prolonged duration, spontaneous activity, high-amplitude contractions, and lower esophageal sphincter abnormalities may be seen in diffuse esophageal spasm. None of these findings alone or in combination justifies a diagnosis of diffuse esophageal spasm unless associated with simultaneous esophageal contractions.

The roentgen diagnosis of diffuse esophageal spasm.

THE ROENTGEN DIAGNOSIS OF DIFFUSE ESOPHAGEAL SPASMEDMUND F. MCNALLY, M.D. and ISADORE KATZ, M.D.Audio Available | Share