Distal esophageal spasm with multiple esophageal diverticula successfully treated by peroral endoscopic myotomy

Abstract

Distal esophageal spasm (DES) is a primary esophageal motility disorder. We encountered a rare case of DES accompanied by multiple esophageal diverticula. A 72-year-old woman complained of prolonged dysphagia and chest pain. A barium esophagogram showed multiple esophageal diverticula and significant contraction of the lower esophagus just above the cardia. Esophagogastroduodenoscopy revealed a corkscrew-like appearance, with spiral contractions and diverticula. High-resolution manometry revealed that the integrated relaxation pressure was normal; premature contractions were observed in ≥20% of the swallowing wave; the distal contractile integral was normal. She was diagnosed with DES according to the Chicago classification v 3.0. As smooth muscle relaxants were not effective, we decided to perform peroral endoscopic myotomy (POEM) to eliminate persistent esophageal contraction. After POEM treatment, her symptoms were markedly improved, and the Eckardt score significantly decreased from 11 points to 1. An esophagogram after POEM showed that barium flowed promptly into the stomach. The multiple esophageal diverticula were considered to be the result of false pulsion diverticulosis caused by excessive internal esophageal pressure, and this represented the most severe form of DES. POEM could be a new curative strategy for the most severe DES cases with multiple diverticula.

Experience with Peroral Endoscopic Myotomy for Achalasia and Spastic Esophageal Motility Disorders at a Tertiary U.S. Center

“…Overall, experience with POEM for treating these conditions remains limited, but the results of reported series are promising. [12][13][14][15] In this series, one of the 3 patients with DES did not achieve clinical success. In this case, the chest pain improved but the dysphagia persisted.…”

Long-term outcomes of per-oral endoscopic myotomy in a patient with distal esophageal spasm followed up for 2.5 years: two sides of the same coin – A Case Report and Literature Review

“…Many agents which can relax smooth muscle as PPIs, nitric oxide, calcium channel blockers, and phosphodiesterase-5 inhibitors have been routinely used. In addition, though the data does not show a clear benefit, tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors are also used for chest pain [13,14]. While it is clear from this case, patients with severe dysphasia and chest pain cannot tolerate oral medication.…”

Epiphrenic diverticula: An added source of complexity in achalasia management

“…A recent international, multicenter trial of 11 patients with an esophageal diverticulum (Zenker's 7, mid‐esophageal 1, and epiphrenic 3) who underwent D‐POEM had a technical success rate of 90.9% and clinical success in all 10 remaining patients . POEM has also been successful for other primary esophageal motility disorders in the setting of diverticula, such as diffuse esophageal spasm . However, the response rates of primary esophageal motility disorders vary widely, from 96% in patients with diffuse esophageal spasm to 70% with a hypercontractile esophagus .…”

“…16 POEM has also been successful for other primary esophageal motility disorders in the setting of diverticula, such as diffuse esophageal spasm. 17 However, the response rates of primary esophageal motility disorders vary widely, from 96% in patients with diffuse esophageal spasm to 70% with a hypercontractile esophagus. 18 As POEM technique is refined for this indication, the management of epiphrenic diverticula will require close collaboration between surgeons and advanced endoscopists for the selection of a personalized treatment approach for each patient.…”