History and Physical Examination

History

Esophageal spasm usually presents with the following intermittent symptoms:

Noncardiac chest pain (< 10% of causes of noncardiac chest pain are due to diffuse esophageal spasm; the pain is usually retrosternal, frequently radiates to the back, and can be more severe than angina.)
Globus (ie, the sensation that an object is trapped in the throat)
Dysphagia, which is more consistent and reproducible during investigative studies, may be reported by one third to two thirds of subjects
Regurgitation
Heartburn (About 20% of patients report heartburn.)

A correlation between uncoordinated contractions and chest pain can be difficult to document, and, usually, a disparity exists between symptoms and the manometric findings.

Symptoms are usually intermittent and variable from day to day. They may last between minutes and hours.

Pain may be associated with eating quickly or drinking hot, cold, or carbonated beverages.

Anxiety and depression are common in these patients.

Patients with nutcracker esophagus or high-amplitude peristaltic contractions usually present with chest pain, as only 10% experience dysphagia.

Physical examination

Physical examination is typically not helpful for making a diagnosis but may provide clues to a systemic disease if this is the underlying cause of the patient's dysphagia.

Differential Diagnoses

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Media Gallery

Barium swallow demonstrates diffuse uncoordinated contractions of the esophagus in a patient with diffuse esophageal spasm.
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.
Esophageal manometry tracing demonstrates diffuse esophageal spasm. Note the multiple uncoordinated contractions in the third tracing from the distal esophagus.
Esophageal manometry tracing demonstrates nutcracker esophagus. Note the excessive amplitude of the contractions.
High-resolution manometric display of a normal esophageal swallow using esophageal pressure topography. Image courtesy of Wikimedia Commons.

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Author

Ahmad Malas, MD Fellow, Department of Gastroenterology, Providence Hospital and Medical Centers

Ahmad Malas, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Janice M Fields, MD, FACG, FACP Assistant Professor of Internal Medicine, Oakland University William Beaumont School of Medicine; Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, St John Macomb-Oakland Hosptial

Janice M Fields, MD, FACG, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

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, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

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.

Alan BR Thomson, MD Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.