Snapshot A 50-year-old woman with a history of acid reflux presents to her primary care physician for intermittent non-exertional chest pain. The pain is not associated with exercise or shortness of breath. She also reports that for the past few months, she has experienced the sensation of food stuck in her throat. She had been worried about her heart, and so she recently had an extensive work-up for coronary artery disease with her cardiologist, all of which were negative. Suspicious for an esophageal etiology for her chest pain, her physician orders an upper gastrointestinal barium swallow study, which shows a corkscrew-like esophagus. She is started on a calcium channel blocker. Introduction Overview diffuse esophageal spasms are non-peristaltic contractions of the esophagus that are simultaneous or uncoordinated Epidemiology incidence likely underdiagnosed due to vague symptoms demographs rare in children more common in women Pathogenesis causes are unclear often precipitated by ingestion of hot or cold liquids possibly due to aberrant neurological signaling Associated conditions gastroesophageal reflux disease depression and anxiety neuromuscular or neurodegenerative disorders Presentation Symptoms chest pain (non-exertional) that may radiate to arm, back, neck, or jaw dysphagia globus Physical exam no specific findings Imaging Upper gastrointestinal barium swallow study findings "corkscrew” or “rosary bead esophagus” only during a spasm not specific to diffuse esophageal spasm Studies Diagnostic approach can be difficult to distinguish from cardiac chest pain and cardiac work up such as electrocardiogram (EKG), stress test, and even coronary angiography is often indicated Invasive studies endoscopy findings normal esophageal manometry indications diagnostic findings shows normal lower esophageal sphincter and normal-amplitude, simultaneous contracts after a swallow Differential Achalasia distinguishing factor increased lower esophageal sphincter function Nutcracker esophagus distinguishing factor coordinated but high amplitude contractions Angina and acute coronary syndrome distinguishing factors cardiac risk factors ↑ cardiac enzymes ST changes on EKG Treatment Medical calcium channel blockers indication reduces severity of spasm nitrates indication reduces severity of spasm proton pump inhibitor indication treats associated reflux tricyclic antidepressant indications treats any associated mood disorder second-line as this has increased side effect profile Surgical botulinum toxin (endoscopic injection) indication refractory to medical therapy myotomy indications refractory to all the above indicated for severe and incapacitating symptoms Complications Lack of response to treatment