• Esophageal spasms present with non-cardia chest pain, which is located retrosternally and radiates to the back. Patients also complain of dysphagia which is characterized by difficulty swallowing several seconds after initiating a swallow, a sensation of food getting stuck and regurgitation. There is also a globus sensation, and many patients suffer from heartburn.
• The symptoms are intermittent and vary in frequency and intensity. Pain may be triggered by particular food and drinks.
• In the hypertensive variants, pain is the predominant symptom, with mild dysphagia [8].

• Movement Disorder

  DES is a movement disorder involving the type of muscle (called smooth muscle) of the esophagus. [uclahealth.org]

• Non-Cardiac Chest Pain

  Diffuse esophageal spasm is an unusual cause of non-cardiac chest pain (2%) or dysphagia (4%). It occurs most commonly in patients >50 years old but can occur at any age. [radiopaedia.org]

  non-cardiac chest pain Internal medicine Chest pain that simulates cardiac nosologies, but is unrelated to cardiovascular disease; 50% of Pts with NCCP have known reflex and may have postprandial or noctural Sx. See Gastroesophageal reflux disease. [medical-dictionary.thefreedictionary.com]

  It can sometimes cause non-cardiac chest pain. The esophagus is the muscular tube that moves food or drink from the throat down into the stomach when you swallow. [dignityhealth.org]

  Theophylline - improved non-cardiac chest pain in one trial, and may relax the oesophageal wall. [patient.info]

• Dysphagia

  Diffuse esophageal spasm typically causes substernal chest pain with nonprogressive dysphagia and odynophagia for both liquids and solids. [ncbi.nlm.nih.gov]

  These observations raise questions about the role of manometry in patients with dysphagia and suspected achalasia. [appliedradiology.com]

  […] spasm Diffuse esophageal spasm (DES) may be present, however, without the appearance of a corkscrew esophagus Usually occurs over the age of 50 Normal esophageal manometry is present, at least intermittently Clinical Findings Chest pain is the hallmark Dysphagia [learningradiology.com]

• Gagging

  The only thing I've found to stop it (never tried the gagging thing) is one drop of essential oils of ginger and peppermint in a cup of water. [ibsgroup.org]

  You are choking, gagging, or vomiting. You have pain when you swallow. You have new or worse chest pain and shortness of breath. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. [drugs.com]

  As the condition can cause a choking or gagging feeling, the spasms often cause anxiety, especially when they have been diagnosed. A person’s symptoms will also tend to worsen towards the end of the day and if they are under stress. [medicalnewstoday.com]

  He has severe hyperactive gag reflex. He gags on certain foods because of their texture. He has no heartburn. He also has the feeling of something being stuck in his throat and hard to get his breath. [medhelp.org]

• Intermittent Dysphagia

  We present a 43-year-old female with paroxysmal chest and abdominal pain, nausea, salivation, and intermittent dysphagia. Esophageal testing demonstrated diffuse esophageal spasm, but smooth muscle relaxants provided no relief. [ncbi.nlm.nih.gov]

  Full Text A 68-year-old man was evaluated in our clinic for intermittent dysphagia, regurgitation of liquids and solids, and chest pain. Esophagogastroduodenoscopy revealed a slightly dilated esophagus with retained food. [elsevier.es]

  The usual presentation is intermittent dysphagia with occasional chest pain. [emedicine.medscape.com]

• Odynophagia

  Diffuse esophageal spasm typically causes substernal chest pain with nonprogressive dysphagia and odynophagia for both liquids and solids. [ncbi.nlm.nih.gov]

  Dysphagia is the most common clinical finding with relatively modest odynophagia. [healio.com]

  Some patients describe odynophagia, although this is not a frequent complaint. References 1. Kramer P (1970) Diffuse esophageal spasm. Mod Treat 7 : 1151-1162. 2. [oeso.org]

  Pain Esophageal pain and painful swallowing (odynophagia) are more commonly seen in nutcracker syndrome. The pain is usually intense and is a squeezing or constricting pain that is typically felt in the chest. [healthhype.com]

• Solid Dysphagia

  Diffuse esophageal spasm typically causes substernal chest pain with nonprogressive dysphagia and odynophagia for both liquids and solids. [ncbi.nlm.nih.gov]

• Chest Pain

  The presentation of esophageal motor disorders may not be clear, particularly when the presenting symptom is chest pain. Determining whether the pain is cardiac or digestive in origin is crucial. [ncbi.nlm.nih.gov]

  […] with diffuse esophageal spasm Diffuse esophageal spasm (DES) may be present, however, without the appearance of a corkscrew esophagus Usually occurs over the age of 50 Normal esophageal manometry is present, at least intermittently Clinical Findings Chest [learningradiology.com]

• Hypertension

  There is no totally effective treatment for the hypertensive variants. Initially calcium channel blockers such as diltiazem may be used. [symptoma.com]

  Abstract The hypertensive peristaltic (nutcracker) esophagus represents a motility disorder characterized clinically by squeezing retrosternal chest pain and manometrically by high amplitude esophageal peristaltic contractions. [ncbi.nlm.nih.gov]

  "The hypertensive lower esophageal sphincter". Digest Dis Sci. 34 : 1063–1067. doi : 10.1007/BF01536375. CS1 maint: Multiple names: authors list ( link ) [en.wikipedia.org]

• Retrosternal Chest Pain

  Abstract The hypertensive peristaltic (nutcracker) esophagus represents a motility disorder characterized clinically by squeezing retrosternal chest pain and manometrically by high amplitude esophageal peristaltic contractions. [ncbi.nlm.nih.gov]

• Muscle Spasm

  Source: iStock Muscle spasm facts Spasms can affect many different types of muscles in the body, leading to many different symptoms. [medicinenet.com]

  When it does cause symptoms, muscle spasms throughout the esophagus typically are felt as chest pain under the breastbone coinciding with difficulty swallowing (dysphagia) liquids (especially those that are very hot or cold) and solids. [merckmanuals.com]

  Muscle spasm. 2.1 secs Friends (1994) - S01E08 The One Where Nana Dies Twice Okay, it's in spasm. 1.4 secs The Odd Couple (2015) - S01E08 The Unger Games - What happened? - Oh, neck spasm! [getyarn.io]

• Leg Cramp

  Leg spasms are often seen related to exercise, but cramps may also be seen at night involving calf and toe muscles. Nocturnal leg cramps and restless legs syndrome are considered a type of sleep disturbance. [medicinenet.com]

• Muscle Cramp

  There may also be associated muscle cramps. Leg spasms are often seen related to exercise, but cramps may also be seen at night involving calf and toe muscles. [medicinenet.com]

There is no laboratory marker that can aid in the diagnosis of these conditions. Since these patients have dysphagia an endoscopy will be required to rule out structural problems. If the symptoms are suggestive of gastroesophageal reflux, empirical treatment may be started. If there is no relief then, the below tests should be done [8]. 

Imaging

The modality of choice is barium swallow and esophageal manometry. A barium swallow will show esophageal spasm as of multiple contractions that appear at the same time causing a corkscrew like appearance. Manometry is the best modality to diagnose esophageal spasm. The variants have characteristic findings. Nutcracker esophagus is characterized by coordinated contractions in the smooth muscle of the esophagus with an excessive amplitude and/or duration. Diffuse esophageal spasm, will have is ≥20 percent premature contractions on esophageal pressure topography.

• Esophageal Motility Disorder

  Barium passes through the lower esophageal sphincter into the stomach. Esophageal Motility Disorders Treatment & Management. Eric A Gaumnitz, and Abdullah Fayyad. eMedicine [learningradiology.com]

  Diffuse esophageal spasm, an uncommon esophageal motility disorder, has recently been defined using high-resolution manometry. Patients with distal esophageal spasm usually complain of chest pain or dysphagia. [ncbi.nlm.nih.gov]

  Tricyclic antidepressants have produced much success in the treatment of many patients with esophageal motility disorders. [emedicine.medscape.com]

• There is no totally effective treatment for the hypertensive variants. Initially calcium channel blockers such as diltiazem may be used. Another option are tricyclic antidepressants and imipramine, which have been shown to be effective in small randomized studies.
• If the initial therapies are not successful, few treatment options remain, including botulinum toxin or a nitric oxide contributing drugs (e.g. isosorbide) or sildenafil.
• For extreme cases myotomy is done to relive the pain. If all fails then a last resort is esophagectomy [9] [10] [11].

Mortality is rare but the morbidity is significant and will affect the quality of life with possible psychological problems developing, especially if the diagnosis is not made. Patients are frequent visitors to the emergency room and often get discharged once cardiac cases are ruled out, leaving them confused with little relief from their pain. These patients are at increased risk of achalasia [7].

The true etiology of the condition and its variants is unknown. There have been hypothesis of nerve disorders and gastroesophageal reflux being a cause. The cause of hypertensive spasms is also unknown, but neuronal disorders appear to be there.

There is very little data outside the United States of America, where the incidence is believed to be 1 case in every 100,000 population year. Mortality is rare, but the quality of life may be significantly reduced if the condition is not diagnosed or treated well. It is more common in Caucasians and women [3]. Some of these esophageal motility disorders have been associated with psychiatric conditions.

The pathophysiology of the condition and its variants is not completely understood, but it is thought that there is a problem with the innervation of the muscles. Esophageal spasm may occur due to a deficiency of nitric oxide synthesis and degradation. This hypothesis was formed because these spams respond to glycerine trinitrate.
The hypertensive variants are thought to be caused by due to overactivity of excitatory innervation or smooth muscle response to excitatory nerves [4] [5] [6].

The true etiology and pathophysiology are not known and prevention is difficult to implement. The spasms may be triggered by certain food and drinks, these can be avoided to reduce the attacks. Use of pureed food has been shown to reduce the frequency of the spasms.

Esophageal spasms can be classified into two different types, diffuse esophageal spasm, with the second form having hypertensive peristalsis.

• Diffuse esophageal spasms has uncoordinated normal amplitude contractions with rapid propagation.
• Hypertensive peristalsis is better known as the nutcracker esophagus and is characterised by coordinated contractions with a high amplitude and pressure. There is another variant called the jackhammer esophagus that is a more severe variant with longer a prolonged contraction and is more diffuse [2]. 

• Definition: Esophageal spasm is a distressing condition where food pipe which carries food from the mouth to the stomach, called the esophagus has involuntary contraction with uncoordinated movement of substances. There are subsets of this condition, e.g. the nutcracker esophagus where the muscles are coordinated, but they contract and squeeze the food pipe tight, causing symptoms.
• Cause: The cause is not known but research is ongoing to try and find out. It is thought in some cases acid from the stomach coming back up the food pipe could be cause.
• Symptoms: Esophageal spasms present with central chest pain. Patients also complain of difficulty in swallowing and regurgitation of food. There is also a sensation of a lump in the throat, and many patients have heartburn. The symptoms are intermittent and vary in frequency and intensity. Pain may be triggered by certain types of food. In the hypertensive variants, pain is the predominant symptom, with mild difficulty in swallowing.
• Diagnosis: The diagnosis is made by seeing how the food pipe contracts. This can be done by doing a barium swallow (you are made to swallow a contrast medium while X-rays are being taken). The other test is done by placing a small pipe in the food pipe and measuring the pressures along the pipe while you swallow. The doctor may also order an endoscopy to see the food pipe to make sure there I nothing blocking it and no acid is come out backward into the food pipe. 
• Treatment: There are tablets that are used to help treat the condition. If that doesn’t work then injection with botulism toxin (Botox) is used to reduce the spasm. The patients should avoid foods and drinks that cause or worsen the spasms.

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3. Katz PO, Dalton CB, Richter JE, et al. Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients. Ann Intern Med 1987; 106:593.
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