Esophageal spasm

Distal esophageal spasm is in uncommon disorder of motility, and its prevalence is between 3 and 9% in symptomatic patients.

Mean age at presentation is approximately 60 years.

There is the slight female predominance at 55%.

There’s a lack of histopathological information.

Studies suggest the tissue is deficient in nitrogen oxide that may impair the inhibitory innervation and allow simultaneous contractions, as well as possible abnormal relaxation of the esophagogastric Junction.

It is suggested that partial mechanical obstruction at the level of the gastroesophageal junction is associated with a manometric pattern characteristic of spasms.

Has comorbidities with hypertension, diabetes, depression, and anxiety.

84%% of patients with abnormal manometric esophageal findings is associated with a psychiatric diagnosis.

The relationship between esophageal spasms and gastroesophageal reflux and acid provoked disease is unclear.

Achalasia has a similar pathophysiologic mechanism.

Patients present with esophageal symptoms which range from mild to severe, typically intermittent in nature lasting from seconds to minutes it may be induced by ingestion of solids of fluids but can be unrelated to meals.

A manometric pattern of spasm is found in patients complaining of dysphasia.

Dysphagia is the most common symptom, followed by chest pain, typical GERD symptoms and atypical GERD symptoms with cough and hoarseness.

Esophageal pain may be associated with esophageal contraction amplitudes, whereas dysphagia may be associated with impaired bolus transit.

Symptoms or generally non-specific.

Weight-loss is an uncommon finding, but 30% of patients with esophageal spasms report weight-loss ranging from 6 to 70 pounds.

Esophageal manometry is the gold standard for diagnosing patients with distal esophageal spasms.

Testing patients with manometry however may not identify symptoms, and because of the intermittent nature of the disorder the absence of manometric abnormalities does not exclude esophageal spasm.

It is felt that nonperistaltic simultaneous contractions induced by wet swallows is the hallmark diagnostic criterion for distal esophageal spasms: The presence of 20% or more simultaneous contractions with amplitude more than 30 mmHg, and the presence of some normal esophageal peristalsis.

High resolution mamonetry evaluating rapid contractions and distal latency criteria are being studied.

Barium esophagram may show corkscrew or rosary bead esophageal spasms.

There is no regularly effective treatment.

Nitrates may improve manometric findings in spasm and provide symptomatic relief.

Nitrates may cause smooth muscle relaxation through the increase of tissue nitrogen oxide.

The usual dosage of isosorbide dinitrate is approximately 5-10 mg sub lingually, 5 to 10 minutes before meals if dysphagia is the presenting symptom or on demand for chest pain.

Phosphodiesterase-five inhibitors can cause relaxation of the smooth muscle through the release of nitrogen oxide controlled by cyclic guanosine monophosphate, leading to reduction in the esophageal contractile amplitude.

Sildenafil 50 mg a day can symptomatically relieve patients with spastic motility.

Calcium channel blockers can lead to smooth muscle relaxation and effectively cause esophageal emptying in dysphasia patients.

Diltiazem 180-240 mg and nifedi10-30 mg 10-15 minutes before meals are recommended.

A trial of tricyclic antidepressants for primarily chest pain is recommended.

Proton pump inhibitors maybe help some patients.

Peppermint oil can relax smooth muscle and improve spasm symptoms.

Peroral endoscopic myotomy can provide relief in patients with spasm, for a short period of time, but because of postoperative complications it is usually not recommended.

Botulinum toxin can inhibit the release of acetylcholine from the cholinergic neurons leading to paralysis of the muscles.

In patients with esophageal spasm with dysphagia, esophageal dilatation is considered with dilators and balloons.

Laparoscopic myotomy from the lower esophageal area has a questionable role compared to medical and endoscopic treatments.

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