Diffuse Esophageal Spasm (Nutcracker Esophagus)

Diffuse Esophagus spasm is a motor disorder of the

esophagus. The cause is unknown, but stress maybe be a
factor. It is more common in women and usually manifest
in middle age. (Agrawal, hila, tutuian, et al., 2006).

Simultaneous esophageal spasms are uncoordinated

contractions of the muscles in the esophagus that –
instead of pushing food through to the stomach – are
ineffective and prevent normal esophageal movement.
Those ineffective diffuse esophageal spasms can be
associated with spastic lower esophageal sphincter in
around 9 percent of cases.

Clinical Manifestations

Diffuse esophageal spasm is characterized by difficulty

(dysphagia) or pain (odynophagia) on swallowing and by
chest pain similar to that of coronary artery spasm.

Assessment and Diagnostic Findings

Esophageal manometry, which measures the motility of the esophagus and the pressure within the
esophagus, indicates that simultaneous contractions of the esophagus occur irregularly. Diagnostic x-ray
studies after ingestion of barium show separate areas of spasm.

Management

Conservative therapy includes administration of sedatives and long acting nitrates to relieve pain.
Calcium channel blockers (e.g., nifedipine [Procardia], verapamil [calan] ) have also been used to
manage diffuse spasm. Small, frequent feedings and soft diet are usually recommended to decrease the
esophageal pressure and irritation that lead to spasm. Dilation performed by bougienage (the use of
progressively sized flexible dilators; see later discussion in the chemical burns section), pneumatic
dilation, or esophagomyotomy may be necessary if the pain becomes intolerable.

If none of the conservative approaches is successful in managing symptoms, surgery may be considered.
The laparoscopic modified Heller myotomy (a surgical procedure in which the cardiac sphincter is cut,
allowing food and liquids to pass into the stomach) is preferred because it has been shown to reduce
reflux better than the open surgical approach. Additionally, it is associated with reduced lengths of
hospital stay and pain as compared to open procedures such as transhiatal esophagectomies or Nissen
fundoplications (Cowgill et al.,2009).