Diffuse Oesophageal Spasm

DEFINITION
Diffuse oesophageal spasm. 
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EPIDEMIOLOGY
Uncommon
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AETIOLOGY

Pathogenesis
Unknown

Complications
Regurgitation and aspiration.
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BIOLOGICAL BEHAVIOUR

Natural history
Progression to achalasia has been documented.
Can be considered together on a spectrum of oesophageal dysmotility.
Chest pain may reflect distension and poor emptying.

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MANIFESTATIONS

Symptoms


Local

Intermittent chest pain
- varies from slight discomfort to simulating angina.
Dysphagia

Systemic
Weight loss is uncommon.

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INVESTIGATIONS

Imaging
Ba swallow is normal in 70%
Fluroscopy shows segmental spasms, narrowings and irregular uncoordinated peristalsis "corkscrew" in 30%.

Manometry
Key test
1. Alteration of peristalsis and disordered (e.g. simultaneous) contractions (normal / low amplitude)
- more than 20$ of contractions are simultaneous not peristaltic
2. Normal LES function or abnormalities similar to those in achalasia (elevated resting pressure, decreased relaxation).

pH Monitoring
Symptoms and picture can be induced by GERD (secondary spasm) --> treat GERD not the spasm.
Exact correlation unknown, but this part of management is treatable so essential.
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MANAGEMENT

Reassure not cardiac problem.

Medical
GORD?
PPIs can help take care of concomitant inciting reflux.
Other
Long-acting nitrates, Calcium channel blockers, sildenafil are variably effective.
Botox = poor results

Operative
Balloon dilation improves symptoms in only 25%.
Laparoscopic (long length) Heller myotomy and partial fundoplication improves dysphagia and chest pain in 70% or so.
- consider if no GORD and symptoms persistent
- bottom line is that unpredictable outcome.
Start myotomy at distal oesophagus and go as far proximal as comfortable.
- vigorously spread muscles apart.
- fundo

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REFERENCES
Doherty.
Cameron.