Diffuse esophageal spasm involves multiple spontaneous and swallow-induced contractions of the esophageal body that are of simultaneous onset and long duration and are recurrent. Causes include the following: primary (idiopathic) or secondary due to gastroesophageal reflux disease, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia, or collagen vascular disease.

An important variant is nutcracker esophagus: high-amplitude (>180 mmHg) peristaltic contractions; particularly associated with chest pain or dysphagia, but correlation between symptoms and manometry is inconsistent. Condition may resolve over time or evolve into diffuse spasm; associated with increased frequency of depression, anxiety, and somatization.

EVALUATION
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
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 dilatation. Rare pts require surgical intervention: longitudinal myotomy of esophageal circular muscle. Treatment of concomitant depression or other psychological disturbance may help.