Esophageal Spasm Syndromes

Presentation

Most patients will have chest pain or complain of dysphagia. The chest pain may in fact be difficult to distinguish from angina. Pain of cardiac origin must be ruled out prior to labeling this an esophageal problem.

Diffuse esophageal spasm results from hypertrophy of the mucsular layers and degeneration of the vagus. Manometry reveals multiple simultaneous or uncoordinated contractions. The lower esophageal sphincter (LES) will have short duration of relaxation and >20% of the distal esophagus will demonstrate simultaneous contractions.

Nutcracker esophagus is the most common of the primary esophageal motility disorders. It is associated with pressure amplitudes of >2 standard deviations from norm and distal esophageal pressures >180 mm Hg. Patients have normal peristaltic progression.

Hypertensive lower esophageal sphincter is associated with normal esophageal perstalsis but with delayed passage of food bolus through the gastroesophageal junction. The LES pressure is >26 mm Hg with relaxation pressures <8 mm Hg.

Diagnosis

Various studies are available to evaluate the esophagus. They include:

1. Barium esophagogram

2. Esophageal manometry

3. Video esophagogram

4. Endoscopy

Management

Esophageal myotomy is the surgical treatment when medical management fails. Long myotomy is performed through al muscle layers of the esophagus through the manometric defect and extended 2-3 cm beyond the GE junction. Following myotomy secondary reflux can be a problem and require surgical intervention. Surgical myotomy is associated with a low morbidity and gives superior long term results. However in practice, pneumatic dilitation is performed with a risk of rupture as high as 20%.

Modified Heller Myotomy

The myotomy is performed through all muscle layers. The myotomy is extended 2 cm beyond the GE junction and 4 cm beyond the defect proximally. A partial fundoplication can be added to prevent reflux disease.

Diverticula

There are three types of esophageal diverticula:

1. Zenkers (crycopharyngeal) diverticulum

2. Epiphrenic diverticulum

3. Traction diverticulum

Traction diverticula are typically midesophageal and associated with a mediasti-nal inflammatory process. Both epiphrenic and Zenkers are pulsion diverticula. Any patient discovered to have a esophageal diverticula should be studied for a motility disorder.

Zenkers is associated with dysphagia, regurgitation of undigested food, halitosis, aspiration. Diagnosis is made with a barium swallow. Endoscopy is not the test of choice in this case. The pathogenesis is the result of crycopharyngeal muscle dysfunction.

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