eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Spasm: Differential Diagnoses & Workup

Author: Alan BR Thomson, MD, MSc, PhD, Professor, Department of Medicine, Division of Gastroenterology, University of Alberta Faculty of Medicine
Contributor Information and Disclosures

Updated: Aug 26, 2009

Differential Diagnoses

Achalasia
Esophageal Webs and Rings
Angina Pectoris
Esophagitis
Esophageal Cancer
Gastroesophageal Reflux Disease
Esophageal Diverticula
Myocardial Infarction
Esophageal Motility Disorders
Esophageal Stricture

Other Problems to Be Considered

  • Studies using catheter-based high-frequency ultrasound imaging have shown an increase in the baseline muscle thickness in patients with DES, nutcracker esophagus, and achalasia, as well as in patients with esophageal symptoms and normal static manometry.
  • Esophageal spasm can modify cardiac function and vice versa. Esophageal spasm and coronary artery disease may coexist.  Mechanisms that cause esophageal spasm can feed back to cause coronary spasm, and coronary spasm may feed forward to cause further esophageal spasm.

Workup

Laboratory Studies

  • Laboratory evaluation usually does not aid in the diagnosis if patients' history and physical examination are unremarkable for other diseases mentioned in the differential diagnosis. All differentials mentioned can present with esophageal dysmotility.
  • The diagnostic modalities of choice are barium swallow and esophageal manometry.
  • Blood sugar and hemoglobin A1C should be checked to rule out diabetes. However, patients can have esophageal spasm and diabetes concomitantly.
  • The findings discovered by monitoring a patient's pH can demonstrate reflux, which can present with somewhat similar symptoms. In fact, gastroesophageal reflux is thought by some to trigger esophageal spasm.

Imaging Studies

  • Barium swallow
    • Barium swallow is the best imaging study to aid in the diagnosis of esophageal spasm.
    • Upon barium swallow, DES has a characteristic appearance of multiple simultaneous contractions. This is often referred to as a corkscrew appearance (see Media file 1 or below).
      Barium swallow demonstrates diffuse uncoordinated...

      Barium swallow demonstrates diffuse uncoordinated contractions of the esophagus in a patient with diffuse esophageal spasm.

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      Barium swallow demonstrates diffuse uncoordinated...

      Barium swallow demonstrates diffuse uncoordinated contractions of the esophagus in a patient with diffuse esophageal spasm.

    • Unlike in DES, the barium swallow findings for nutcracker esophagus are not specific.
  • CT scan
    • Nino-Murcia and colleagues demonstrated thickening of the esophagus with CT scan studies in patients with esophageal spasm.5
    • Muscular hypertrophy has been documented in some patients with DES and nutcracker esophagus.
    • The hypertrophy of the muscle wall is the cause of the increased thickness that is observed on CT scan images. The normal thickness of the esophagus is less than 3 mm.
    • Many other disease processes, including malignancy, cause thickening of the esophagus that can be seen radiographically. Thus, thickening of the esophagus seen on CT scan images should prompt further workup.
    • Even in patients with symptoms consistent with esophageal spasm, thickening seen on CT scan images should not be dismissed as muscular hypertrophy secondary to the esophageal spasms without further investigation.
  • Ultrasound
    • Catheter-based high-frequency intraluminal ultrasound imaging assesses both the sensory function and the motor function of the esophagus.
    • This imaging modality may be useful to distinguish between DES, nutcracker esophagus, and achalasia. 

Other Tests

  • Manometry
    • Manometry is the best modality to help diagnose DES. The classic definition is more than 2 uncoordinated contractions during 10 consecutive wet swallows (≥20% simultaneous esophageal contractions during standardized stationary motility testing). At least one peristaltic contraction must be present. Artificial neural networks may be useful in the recognition and objective classification of primary esophageal motor disorders investigated with stationary esophageal manometry recordings.6 Herbella et al conducted a study in patients with manometric patterns of diffuse esophageal spasm and nutcracker esophagus to determine whether symptoms alone can distinguish primary esophageal motility disorder from gastroesophageal reflux disease, a secondary esophageal motility disorder, and the value of ambulatory pH monitoring.7 Of 180 patients with manometric criteria for nutcracker esophagus, 124 (69%) had gastroesophageal reflux that was detected with ambulatory pH monitoring. Of 56 patients with primary esophageal motility disorder, 31 (55%) were taking proton pump inhibitors.7 There was no difference in chest pain prevalence between the groups, but those with primary esophageal motility disorder had greater chest pain symptom severity, whereas patients in the gastroesophageal reflux group had a higher prevalence and severity of heartburn.7 Of the 121 patients with manometric criteria for diffuse esophageal spasm, 73 (60%) demonstrated gastroesophageal reflux by ambulatory pH monitoring.7 Of the 48 patients with primary esophageal motility disorder, 39 (81%) were on proton pump inhibitors. The group with primary esophageal motility had a higher prevalence of dysphagia disorder relative to the gastroesophageal reflux group.The investigators thus demonstrated that two thirds of patients with a manometric patter of diffuse esophageal spasm or nutcracker esophagus also had gastroesophageal reflux disease, and symptoms were indistinguishable between primary esophageal motility disorders and gastroesophageal reflux disease. Herbella et al concluded esophageal manometry and pH monitoring are crucial to distinguish between primary and secondary esophageal motility disorders and to guide appropriate therapy.7
  • Contraction amplitude is normal.
  • Media file 2 is a normal manometric tracing.
    This is normal esophageal manometry tracing with ...

    This is normal esophageal manometry tracing with normal amplitude of the contractions. The contractions are coordinated because the contractions in the proximal esophagus (top of image) occur before the contractions further distal in the esophagus.

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    This is normal esophageal manometry tracing with ...

    This is normal esophageal manometry tracing with normal amplitude of the contractions. The contractions are coordinated because the contractions in the proximal esophagus (top of image) occur before the contractions further distal in the esophagus.

    Media file 3 is an example of DES.
    Esophageal manometry tracing demonstrates diffuse...

    Esophageal manometry tracing demonstrates diffuse esophageal spasm. Note the multiple uncoordinated contractions in the third tracing from the distal esophagus.

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    Esophageal manometry tracing demonstrates diffuse...

    Esophageal manometry tracing demonstrates diffuse esophageal spasm. Note the multiple uncoordinated contractions in the third tracing from the distal esophagus.

  • Manometry in patients with nutcracker esophagus demonstrates contractions that progress in an orderly manner, but the amplitude of the contraction is excessive. Amplitude greater than 2 standard deviations above the normal value is considered diagnostic for nutcracker esophagus (see Media file 4 or below).
    Esophageal manometry tracing demonstrates nutcrac...

    Esophageal manometry tracing demonstrates nutcracker esophagus. Note the excessive amplitude of the contractions.

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    Esophageal manometry tracing demonstrates nutcrac...

    Esophageal manometry tracing demonstrates nutcracker esophagus. Note the excessive amplitude of the contractions.

  • There may be a disassociation between symptoms and manometric findings.
  • Esophageal electrical impedance recordings show abnormal transit in DES.
  • Esophageal manometry may be combined with multichannel intraluminal impedance to obtain pressure and bolus transit information.8 About one half of patients with DES have normal transit for liquids and fluids, one fourth have abnormal transit for one substance, and one fourth have abnormal transit for both.
  • Esophageal pH recording and 24-hour ambulatory manometry may improve the detection of esophageal muscle dysfunction. This method shows that, in persons presenting with noncardiac chest pain, gastroesophageal reflux symptoms are common and DES is rare.
  • Endoscopy: This test is not useful to help diagnose dysmotility, but it may be helpful to exclude erosive esophagitis or stricture.

More on Esophageal Spasm

Overview: Esophageal Spasm
Differential Diagnoses & Workup: Esophageal Spasm
Treatment & Medication: Esophageal Spasm
Follow-up: Esophageal Spasm
Multimedia: Esophageal Spasm
References
Further Reading
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References

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

esophageal spasm, diffuse esophageal spasm, nutcracker esophagus, DES, dysphagia, regurgitation, achalasia, noncardiac chest pain, esophagectomy, globus, gastric reflux, gastric reflux, microvascular compression of Vagus nerve

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Contributor Information and Disclosures

Author

Alan BR Thomson, MD, MSc, PhD, Professor, Department of Medicine, Division of Gastroenterology, University of Alberta Faculty of Medicine
Alan BR Thomson, MD, MSc, PhD is a member of the following medical societies: American Federation for Aging Research, American Federation for Clinical Research, American Gastroenterological Association, American Geriatrics Society, American Physiological Society, Canadian Association of Gastroenterology, Gastroenterology Research Group, New York Academy of Sciences, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

John Gunn Lee, MD, Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine
John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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