A 58-year-old woman presents to the clinic with intermittent episodes of substernal chest pain and difficulty swallowing for the past three months. Symptoms occur unpredictably and may be triggered by either hot or cold beverages. She reports that the pain occasionally mimics her prior episodes of angina, but extensive cardiac evaluation, including stress testing, was normal. The dysphagia occurs with both solids and liquids. Past medical history is significant for coronary artery disease. She takes aspirin, lisinopril, and atorvastatin. Vital signs are within normal limits. Physical examination is unremarkable. Upper endoscopy demonstrates no structural abnormalities.
Which of the following is the most likely diagnosis?
The correct answer is:
B) Diffuse esophageal spasm
This patient has classic diffuse esophageal spasm (DES), characterized by intermittent dysphagia to both solids and liquids accompanied by noncardiac chest pain. The normal cardiac evaluation is an important clue because DES frequently mimics angina. Another characteristic feature is symptom provocation by very hot or cold beverages. The intermittent nature of symptoms helps distinguish DES from progressive mechanical obstruction.
Diffuse esophageal spasm results from abnormal, uncoordinated contractions of the esophageal body. Unlike achalasia, lower esophageal sphincter relaxation is generally preserved. Because esophageal contractions occur in a disorganized fashion, bolus transit becomes inefficient, leading to episodic dysphagia and chest discomfort. Diagnosis is confirmed by esophageal manometry, which demonstrates premature or simultaneous contractions. Barium swallow studies may reveal a characteristic “corkscrew esophagus.”
A high-yield Step 2 distinction is the difference between DES and achalasia. Both disorders can cause dysphagia to solids and liquids, but achalasia typically presents with progressive symptoms and impaired lower esophageal sphincter relaxation. In contrast, DES causes intermittent symptoms and normal LES relaxation. Management often includes calcium channel blockers, nitrates, and treatment of associated reflux symptoms.
Answer choice A: Achalasia, is incorrect.
Achalasia is a common distractor because both conditions cause dysphagia to solids and liquids. However, achalasia generally causes progressively worsening symptoms and is characterized by impaired lower esophageal sphincter relaxation on manometry.
Answer choice C: Esophageal adenocarcinoma, is incorrect.
Esophageal cancer usually causes progressively worsening dysphagia that begins with solids and later involves liquids. The intermittent nature of this patient’s symptoms argues against malignancy.
Answer choice D: Gastroesophageal reflux disease, is incorrect.
GERD commonly causes heartburn and regurgitation. Although chest discomfort may occur, GERD does not typically cause intermittent dysphagia to both solids and liquids with normal endoscopic findings.
Answer choice E: Zenker diverticulum, is incorrect.
Zenker diverticulum causes oropharyngeal dysphagia, halitosis, aspiration, and regurgitation of undigested food. These features are absent in this patient.
Key Learning Point
Diffuse esophageal spasm causes intermittent dysphagia to solids and liquids along with noncardiac chest pain and is diagnosed by esophageal manometry demonstrating uncoordinated esophageal contractions.
