Esophageal achalasia vs Diffuse esophageal spasm
How to tell Esophageal achalasia and Diffuse esophageal spasm apart when a board question makes them look alike.
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Elevated LES integrated relaxation pressure on manometry identifies achalasia rather than diffuse esophageal spasm.
Side by side
Progressive dysphagia to solids and liquids with regurgitation and weight loss plus impaired LES relaxation suggests achalasia.
Intermittent chest pain and dysphagia with normal LES relaxation but premature contractions on manometry suggests diffuse esophageal spasm.
Loss of inhibitory myenteric neurons raises LES tone and abolishes coordinated distal peristalsis.
Disordered inhibitory signaling produces uncoordinated high-amplitude premature distal contractions while LES relaxation is preserved.
High-resolution manometry shows elevated integrated relaxation pressure above 15 mm Hg with 100 percent failed peristalsis; timed barium swallow shows bird-beak tapering and retained column at 5 minutes.
High-resolution manometry shows at least 20 percent premature contractions with distal latency under 4.5 seconds and normal median LES integrated relaxation pressure.
The trap
Both disorders can produce chest pain and dysphagia, so treating presumed reflux or anxiety without manometry delays definitive therapy; preserved LES relaxation redirects toward spasm treatment instead of achalasia procedures.
The repair move
Next best step: confirm motility pattern with high-resolution manometry after excluding pseudoachalasia by endoscopy when red flags are present, then offer definitive achalasia therapy such as pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. If the pattern is diffuse esophageal spasm with normal LES relaxation, start smooth-muscle relaxation therapy such as diltiazem 60 to 90 mg PO three times daily or a long-acting nitrate before meals.
Try a free question
CoreA 45-year-old woman has progressive dysphagia to both solids and liquids and regurgitation of undigested food. BP 136/82 mm Hg, HR 84/min, temp 36.7 C. Endoscopy shows no obstructing lesion. Manometry demonstrates LES integrated relaxation pressure 22 mm Hg and absent peristalsis. What is the next best step in management?
Show answer and explanation
Answer: A. Offer definitive achalasia therapy such as pneumatic dilation or Heller myotomy. Confirmed achalasia with impaired LES relaxation is managed with LES-directed definitive intervention.
Why the other choices are tempting
- B. Wrong because diltiazem is more appropriate for diffuse spasm when LES relaxation is preserved.
- C. Wrong because acid suppression does not correct achalasia physiology.
- D. Wrong because reassurance alone delays treatment and worsens nutritional compromise.
- E. Wrong because colectomy is unrelated to esophageal motility disease.
Flashcards
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Which manometry metric most quickly separates achalasia from diffuse esophageal spasm?
Integrated relaxation pressure of the LES: elevated in achalasia and usually normal in diffuse esophageal spasm.
What distal latency cutoff supports diffuse esophageal spasm on high-resolution manometry?
Premature contractions with distal latency under 4.5 seconds support diffuse esophageal spasm.
Quick answers
What is the fastest way to tell Esophageal achalasia from Diffuse esophageal spasm?
Elevated LES integrated relaxation pressure on manometry identifies achalasia rather than diffuse esophageal spasm.
What is the key clue for Esophageal achalasia?
Progressive dysphagia to solids and liquids with regurgitation and weight loss plus impaired LES relaxation suggests achalasia.
What is the key clue for Diffuse esophageal spasm?
Intermittent chest pain and dysphagia with normal LES relaxation but premature contractions on manometry suggests diffuse esophageal spasm.
What is the common trap with Esophageal achalasia vs Diffuse esophageal spasm?
Both disorders can produce chest pain and dysphagia, so treating presumed reflux or anxiety without manometry delays definitive therapy; preserved LES relaxation redirects toward spasm treatment instead of achalasia procedures.