A 50-year-old woman comes to the office with a several-month history of intermittent, substernal chest pain. Her pain is not related to activity, does not radiate, and occurs in episodes lasting from a few seconds to a few minutes. During the episodes, she has difficulty swallowing both liquids and solids. She has no associated weight loss or change in appetite. The patient was recently seen in the emergency department due to sudden worsening of the pain; her evaluation included a normal ECG, normal cardiac biomarkers, and a negative myocardial perfusion scan. Past medical history is notable for hypertension, for which she takes chlorthalidone. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination and upper gastrointestinal endoscopy reveal no abnormalities. Which of the following is the most likely diagnosis?

Question

A 50-year-old woman comes to the office with a several-month history of intermittent, substernal chest pain.  Her pain is not related to activity, does not radiate, and occurs in episodes lasting from a few seconds to a few minutes.  During the episodes, she has difficulty swallowing both liquids and solids.  She has no associated weight loss or change in appetite.  The patient was recently seen in the emergency department due to sudden worsening of the pain; her evaluation included a normal ECG, normal cardiac biomarkers, and a negative myocardial perfusion scan.  Past medical history is notable for hypertension, for which she takes chlorthalidone.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Physical examination and upper gastrointestinal endoscopy reveal no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d3e4_64c0_bc81_356b1d0024cb_MD0003_00 This patient with intermittent non-cardiac chest pain and dysphagia has typical symptoms of diffuse esophageal spasm (DES). DES is characterized by uncoordinated, simultaneous contractions of the esophageal body, likely related to impaired inhibitory innervation in the esophagus. DES is frequently seen in association with emotional factors and functional gastrointestinal disorders. Symptoms often resemble those in achalasia (impaired esophageal motility with incomplete relaxation at the lower esophageal sphincter) and nutcracker esophagus (excessive tone at the lower esophageal sphincter). The diagnosis of DES is challenging due to the episodic nature of clinical features. Esophageal manometry reveals intermittent peristalsis and multiple nonperistaltic simultaneous contractions of the middle and lower esophagus. The lower esophageal sphincter usually shows normal relaxation. Esophagram may show nonperistaltic contractions producing a "corkscrew esophagus" pattern, although this is neither sensitive nor specific. Endoscopy is usually normal. First-line treatment includes calcium channel blockers (eg, diltiazem), which relieve pain and reduce dysphagia. (Choice A) Variant (Prinzmetal) angina is due to coronary artery spasm. Typical symptoms include episodic chest pain at rest. Patients may have normal ECG findings between attacks, with variable ST abnormalities during acute events. Variant angina does not explain the patient's dysphagia. (Choice B) Costosternal syndrome (costochondritis) usually occurs after repetitive activity. It is characterized by pain that is reproducible with palpation and worsened with movement or position changes. It would not cause dysphagia. (Choice D) Eosinophilic esophagitis is characterized by food impaction, dysphagia, or heartburn that does not respond to standard medications. Endoscopy usually reveals esophageal rings or strictures. (Choice E) Globus sensation is a functional disorder of the esophagus characterized by the sensation of a foreign body in the throat. It is often worse when swallowing saliva and is frequently associated with anxiety. Pain, dysphagia, dysphonia, or systemic symptoms are not typical for globus and suggest another condition. (Choice F) Zenker diverticulum is a disorder of the proximal esophagus and is generally asymptomatic, although it can cause a sensation of food sticking in the throat, halitosis, and regurgitation. Chest pain is not a typical symptom. Educational objective: Diffuse esophageal spasm is characterized by uncoordinated contractions of the esophagus and presents with chest pain and dysphagia. Esophageal manometry reveals multiple simultaneous contractions of the middle and lower esophagus. Esophagram may show a "corkscrew" pattern. First-line treatment includes calcium channel blockers. References: Physiology of diffuse esophageal spasm (DES)--when normal swallows are not normal. (http://www.ncbi.nlm.nih.gov/pubmed/20565688)

A 50-Year-Old Woman Comes to the Office with a Several-Month