A 40-year-old woman comes to the office due to intermittent dysphagia for the past several months. The patient says, "I frequently have a sensation of food getting stuck in my chest several seconds after swallowing along with pain behind the sternum. I have noticed no specific triggers and have had several episodes after swallowing liquids also." The patient reports no weight loss, nausea, vomiting, hematemesis, abdominal pain, or melena. She has a history of iron deficiency anemia due to menorrhagia from uterine fibroids. The patient has not been taking oral iron supplements due to associated constipation. She does not use tobacco, alcohol, or illicit drugs. Family history is notable for systemic sclerosis in the patient's sister. Vital signs are within normal limits and physical examination shows no abnormalities. Barium esophagogram is normal. Manometry after a test swallow demonstrates premature and simultaneous contractions of the distal esophagus. Lower esophageal sphincter relaxation is normal. Hemoglobin is 10.8 g/dL. Which of the following is the most accurate response to the patient regarding her current symptoms?

Question

A 40-year-old woman comes to the office due to intermittent dysphagia for the past several months.  The patient says, "I frequently have a sensation of food getting stuck in my chest several seconds after swallowing along with pain behind the sternum.  I have noticed no specific triggers and have had several episodes after swallowing liquids also."  The patient reports no weight loss, nausea, vomiting, hematemesis, abdominal pain, or melena.  She has a history of iron deficiency anemia due to menorrhagia from uterine fibroids.  The patient has not been taking oral iron supplements due to associated constipation.  She does not use tobacco, alcohol, or illicit drugs.  Family history is notable for systemic sclerosis in the patient's sister.  Vital signs are within normal limits and physical examination shows no abnormalities.  Barium esophagogram is normal.  Manometry after a test swallow demonstrates premature and simultaneous contractions of the distal esophagus.  Lower esophageal sphincter relaxation is normal.  Hemoglobin is 10.8 g/dL.  Which of the following is the most accurate response to the patient regarding her current symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c151_da66_8f63_5b1f3c6c537d_MD0005_00 This patient with dysphagia and retrosternal chest pain that occur within seconds of eating likely has diffuse (or distal) esophageal spasm (DES). Patients frequently experience a sensation of both solids and liquids getting stuck; this sensation may be triggered by the ingestion of hot or cold foods. Because DES is associated with gastroesophageal reflux disease, some patients with DES who present with heartburn may initially be misdiagnosed. DES may be due to impairment of the inhibitory neurons that innervate the esophagus, causing disordered and premature simultaneous contractions of the distal esophagus. The gold standard for diagnosis is esophageal manometry, which would show premature contractions with normal distal esophageal sphincter relaxation. Barium swallow may show a corkscrew appearance of the esophagus; however, this is neither sensitive nor specific for diagnosis. Current first-line therapy is calcium channel blockers. Tricyclic antidepressants are also suggested for patients who present primarily with chest pain. (Choice A) Systemic sclerosis causes progressive collagen deposition and fibrosis of multiple tissues, including the smooth muscle integral for gastrointestinal motility. Patients may present with dysphagia and heartburn, but esophageal manometry would show evidence of hypomotility with low amplitude contractions and low sphincter pressure. (Choice B) Eosinophilic esophagitis frequently presents with similar symptoms of dysphagia, odynophagia, and heartburn. However, this condition is seen more frequently in men and is highly associated with other allergic conditions (eg, asthma, allergic rhinitis, food allergy). Esophageal manometry findings are nonspecific. (Choice D) Achalasia is caused by failure of the lower esophageal sphincter to relax due to degeneration of the ganglia in the Auerbach plexus. Secondary achalasia can be caused by infection with Trypanosoma cruzi (Chagas disease). An esophagogram typically reveals a dilated esophagus with a "bird's beak" narrowing of the distal esophagus. (Choice E) Plummer-Vinson syndrome is the triad of iron deficiency anemia, dysphagia, and esophageal web. The webs would be seen on barium esophagram (or upper endoscopy), and manometry would not show simultaneous contractions. The webs generally improve with iron repletion. Educational objective: Diffuse esophageal spasm is a motility disorder characterized by disordered and premature simultaneous contractions of the distal esophagus with normal distal esophageal sphincter relaxation as demonstrated by manometry. Patients may present with chest pain and dysphagia. First-line treatment is with calcium channel blockers.

A 40-Year-Old Woman Comes to the Office Due to Intermittent