A 35-year-old woman comes to the physician with a 5-month history of episodic retrosternal pain that radiates to the interscapular region. The episodes typically last 15 minutes, although they occasionally can last a few hours, and are precipitated by emotional stress and hot or cold food. She regurgitates food intermittently. The patient's past medical history is unremarkable, and she takes no medications. There is no family history of coronary artery disease. Her vital signs are within normal limits. Physical examination shows no abnormalities. A lipid profile is within normal limits. An electrocardiogram (ECG) during a pain episode shows a normal sinus rhythm without ST-segment changes. Sublingual nitroglycerin tablets alleviate the pain. A stress test fails to reproduce the symptoms or to induce ST/T-wave changes. Chest x-ray, upper gastrointestinal endoscopy, and echocardiography show no abnormalities. Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old woman comes to the physician with a 5-month history of episodic retrosternal pain that radiates to the interscapular region.  The episodes typically last 15 minutes, although they occasionally can last a few hours, and are precipitated by emotional stress and hot or cold food.  She regurgitates food intermittently.  The patient's past medical history is unremarkable, and she takes no medications.  There is no family history of coronary artery disease.  Her vital signs are within normal limits.  Physical examination shows no abnormalities.  A lipid profile is within normal limits.  An electrocardiogram (ECG) during a pain episode shows a normal sinus rhythm without ST-segment changes.  Sublingual nitroglycerin tablets alleviate the pain.  A stress test fails to reproduce the symptoms or to induce ST/T-wave changes.  Chest x-ray, upper gastrointestinal endoscopy, and echocardiography show no abnormalities.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's symptoms (ie, spontaneous pain, odynophagia for cold and hot food) are suggestive of diffuse esophageal spasm. Resolution of her chest pain after taking nitroglycerin is also consistent with the diagnosis. Nitrates (and calcium channel blockers) relax not only myocytes in coronary vessels but also smooth muscle cells in the esophagus, thereby alleviating the pain. Esophagography may or may not show other anomalies (eg, corkscrew shape). Esophageal manometry should show repetitive, nonperistaltic, high-amplitude contractions, either spontaneously or after ergonovine stimulation. (Choice A) Radiation of pain to the back and its precipitation by emotional stress make the diagnosis of motility disorder more likely than gastroesophageal reflux disease (GERD). GERD most commonly causes burning discomfort (heartburn) rather than radiating pain and is associated with esophagitis on endoscopy. Furthermore, if GERD were suspected, the patient should be started on an empiric trial of a proton pump inhibitor rather than 24-hour pH monitoring. (Choice B) Most cardiac etiologies have been fairly well excluded by this workup, although this patient's symptoms may also raise suspicion for variant (Prinzmetal) angina. However, several features of her presentation, including the duration of pain (up to several hours), regurgitation, and the absence of ST changes during one of the episodes, make these less likely. (Choice C) A CT scan of the chest with contrast would be helpful in diagnosing a pulmonary embolism or an aortic dissection. However, this patient's symptoms, including provocation by stress and food, regurgitation, and relief by nitroglycerin, make both of these diagnoses less likely. (Choice E) Repetitive pulmonary embolism is unlikely with normal vital signs and no shortness of breath. Educational objective: Episodes of dysphagia, regurgitation, and/or chest pain precipitated by emotional stress should raise the suspicion for esophageal motility disorder such as diffuse esophageal spasm. Manometry establishes the diagnosis of diffuse esophageal spasm. References: Management of spastic disorders of the esophagus. (http://www.ncbi.nlm.nih.gov/pubmed/23452629)

A 35-Year-Old Woman Comes to the Physician with a 5-Month