How is a diffuse esophageal spasm distinguished on manometry?

Updated: Aug 07, 2019
  • Author: Ahmad Malas, MD; Chief Editor: BS Anand, MD  more...
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Diffuse esophageal spasm, when defined by premature contractions measured with distal latency, describes a more clinically homogeneous entity than when defined by contractile front velocity. [15]

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. [16]

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. [17] Of the 180 patients with manometric criteria for nutcracker esophagus, 124 (69%) had gastroesophageal reflux that was detected with ambulatory pH monitoring. Of the 56 patients with primary esophageal motility disorder, 31 (55%) were taking proton pump inhibitors. [17] No difference in chest pain prevalence was noted 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. [17]

Of the 121 patients with manometric criteria for diffuse esophageal spasm, 73 (60%) demonstrated gastroesophageal reflux by ambulatory pH monitoring. [17] 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.

Herbella et al thus demonstrated that two thirds of patients with a manometric pattern of diffuse esophageal spasm or nutcracker esophagus also had gastroesophageal reflux disease, and the symptoms were indistinguishable between primary esophageal motility disorders and gastroesophageal reflux disease. They concluded that esophageal manometry and pH monitoring are crucial to distinguish between primary and secondary esophageal motility disorders and to guide appropriate therapy. [17]

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