Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

📖 About

• 💢 Diffuse Oesophageal Spasm (DOS) – a rare motility disorder of the oesophagus.
• ⚠️ Often misdiagnosed as Acute Coronary Syndrome (ACS) because of similar retrosternal chest pain.

🧬 Aetiology

• Caused by severe, uncoordinated oesophageal dysmotility leading to simultaneous non-propulsive contractions.

🩺 Clinical Features

• ⏱️ Episodes of painful oesophageal spasm lasting minutes, colicky in nature.
• 🥤 May be triggered by hot/cold drinks, stress, or eating quickly.
• 💔 Chest pain may mimic angina – important differential for ACS.
• 🌀 Dysphagia (intermittent) may also be present.

🔍 Investigations

• 📸 Barium swallow: classically shows a “corkscrew oesophagus”.
• 📊 Manometry: reveals high amplitude, non-peristaltic contractions → sometimes termed “nutcracker oesophagus”.
• 🧪 Bloods/ECG often done to exclude ACS in acute chest pain presentations.

💊 Management

• 🚭 Lifestyle: avoid triggers (extremes of temperature, rapid eating).
• 💊 Medical: Calcium channel blockers (e.g. diltiazem) and Nitrates can help relax smooth muscle.
• 💉 Botox injection to lower oesophageal sphincter sometimes considered.
• 🔪 Surgical: Long oesophageal myotomy involving the lower sphincter, often combined with a fundoplication to prevent reflux.

📚 References

• Oxford Handbook of Gastroenterology & Hepatology
• BMJ Best Practice – Oesophageal Motility Disorders

Cases — Diffuse Oesophageal Spasm (DES)

• Case 1 — Chest Pain Mimicking Angina ❤️: A 55-year-old man presents with recurrent episodes of central chest pain radiating to the back, often triggered by cold drinks. Pain not related to exertion, ECG and troponins normal. Barium swallow shows a “corkscrew oesophagus”. Diagnosis: Diffuse oesophageal spasm. Management: Exclude ACS first; calcium channel blockers or nitrates; reassurance and dietary modification.
• Case 2 — Dysphagia with Intermittent Symptoms 🍽️: A 62-year-old woman reports intermittent dysphagia to both solids and liquids, worse with stress. Endoscopy normal, but oesophageal manometry shows uncoordinated, simultaneous contractions. Diagnosis: DES confirmed on manometry. Management: Calcium channel blockers, low-dose tricyclics (neuromodulation), dietary adaptation, speech and swallow therapy.
• Case 3 — DES in Patient with Anxiety 🧠: A 48-year-old teacher with generalised anxiety disorder describes episodic chest tightness, dysphagia, and globus sensation. Endoscopy is normal; manometry shows non-peristaltic contractions. Diagnosis: Diffuse oesophageal spasm with psychogenic trigger. Management: Lifestyle measures (slow eating, small meals), pharmacological therapy (nitrates/CCBs), psychological support/CBT for underlying anxiety.

Teaching Commentary 🧠

Diffuse oesophageal spasm is a rare motility disorder characterised by uncoordinated, non-peristaltic contractions of the oesophagus. - Presents with intermittent chest pain and dysphagia (solids + liquids). - Investigations: Barium swallow (“corkscrew” oesophagus); manometry (simultaneous contractions). Endoscopy usually normal. - Management: Lifestyle modification, smooth muscle relaxants (CCBs, nitrates), neuromodulators (low-dose antidepressants). Severe cases may need endoscopic/surgical myotomy.