Distal Esophageal Spasm in High-Resolution Esophageal Pressure Topography: Defining Clinical Phenotypes

Abstract

BACKGROUND The manometric diagnosis of distal esophageal spasm (DES) uses “simultaneous contractions” as a defining criterion, ignoring the concept of short latency distal contractions as an important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES. METHODS Two thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed. RESULTS Of 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 [17.4%] using conventional manometry criteria; n = 85 [7.9%] using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES. CONCLUSIONS The current DES diagnostic paradigm focused on “simultaneous contractions” identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

“…Physiologically, premature contractions imply dysfunction of the inhibitory neurons of the oesophageal myenteric plexus and are the defining characteristic of distal oesophageal spasm and type III achalasia in CC v3.0 (REF. 16). The distal latency is measured as the interval from UES relaxation to the contractile deceleration point (CDP), the inflection point in the wave front velocity just proximal to the EGJ.…”

Anxiety can significantly explain bolus perception in the context of hypotensive esophageal motility: Results of a large multicenter study in asymptomatic individuals

“…Vigorous peristalsis is only occasionally present in patients with dysphagia or chest pain (never more than 5% even using HRM) 34,35 . There is evidence that the correction of this manometric pattern does not necessarily correlate with symptom improvement 36 and viceversa 37 .…”

Esófago en martillo neumático (Jackhammer), serie de casos y revisión del tema

“…Richter y Castell (11), realizaron un estudio en el que encontraron que menos del 5% de los pacientes con esta sintomatología presentaban trastornos de la peristalsis demostrables por manometría esofágica. La prevalencia combinada de espasmo esofágico distal, acalasia espástica y esófago en martillo neumático, es tan solo de aproximadamente el 2% (12,13). El deterioro del tránsito del bolo esofágico, puede ser la causa de las contracciones espásticas, lo cual puede explicar la disfagia.…”