Barium swallow shows corkscrew esophagus, pseudodiverticula, and diffuse spasm. Manometry shows spasm with multiple simultaneous esophageal contractions of high amplitude and long duration. In nutcracker esophagus, the contractions are peristaltic and of high amplitude. If heart disease has been ruled out, edrophonium, ergonovine, or bethanechol can be used to provoke spasm.
Treatment: Spastic Disorders Anticholinergics are usually of limited value; nitrates (isosorbide dinitrate, 5-10 mg PO ac) and calcium antagonists (nifedipine, 10-20 mg PO ac) are more effective. Those refractory to medical management may benefit from balloon dilation. Rare pts require surgical intervention: longitudinal myotomy of esophageal circular muscle. Treatment of concomitant depression or other psychological disturbance may help. |
Section 3. Common Patient Presentations