Symptoms and diagnosis of distal oesophageal spasm

Distal oesophageal spasm can cause dysphagia and regurgitation (typically intermittent and variable), and occasionally food impaction. It is also a cause of noncardiac chest pain, possibly precipitated by gastro-oesophageal reflux.

In most patients, investigations (eg barium swallow, oesophageal manometry) are not required to diagnose distal oesophageal spasm. If the patient fulfils the criteria for upper gastrointestinal endoscopy (see Indications for upper gastrointestinal endoscopy in patients with symptoms suspected to be due to gastro-oesophageal reflux), this should be performed; however, this is not a sensitive investigation. If symptoms are consistent with distal oesophageal spasm, it is appropriate to treat the patient empirically (see Management of distal oesophageal spasm) and reassess for symptom responseGorti, 2020. If the patient does not respond to treatment, further investigation is appropriate to exclude other conditions and confirm the diagnosis. Barium swallow is likely to demonstrate uncoordinated contractions, and sometimes a corkscrew oesophagus. Oesophageal manometry is the most sensitive and specific investigation—it provides information on lower oesophageal sphincter dysfunction to differentiate oesophageal spasm from achalasia.

Opioid-induced oesophageal dysfunction can present with similar symptoms to distal oesophageal spasm. It may be indistinguishable on oesophageal manometry. Opioid-induced oesophageal dysfunction more commonly occurs in patients using oxycodone than other analgesics (eg tramadol)Snyder, 2020. Reassess the need for the opioid and cease if possibleSnyder, 2020.

Cardiac disease should be excluded before symptoms are attributed to distal oesophageal spasm. For the investigation and treatment of undifferentiated acute chest pain, see Acute chest pain of possible cardiac origin.

The long-term course of distal oesophageal spasm is benign, provided significant cardiac disease has been excluded.