From the Guidelines
In jackhammer esophagus and diffuse esophageal spasm, DCI is significantly elevated and DL is shortened, respectively, leading to hypercontractility and premature contractions. In jackhammer esophagus, DCI is significantly elevated (>8,000 mmHg·s·cm) in at least 20% of swallows, indicating hypercontractility, while DL remains normal (>4.5 seconds) 1. In contrast, diffuse esophageal spasm features premature contractions with at least 20% of swallows having a shortened DL (<4.5 seconds), while DCI may be normal or elevated but typically not as high as in jackhammer esophagus.
Key Treatments
Four treatments effective for both conditions include:
- Proton pump inhibitors (such as omeprazole 20-40mg daily or esomeprazole 20-40mg daily) to manage any underlying reflux
- Smooth muscle relaxants like calcium channel blockers (nifedipine 10-30mg before meals) or nitrates (isosorbide dinitrate 5-10mg sublingually as needed)
- Low-dose antidepressants (such as amitriptyline 10-50mg at bedtime) to modulate pain perception
- Endoscopic botulinum toxin injection (100 units) into the lower esophageal sphincter and distal esophagus, as suggested by recent clinical practice updates 1. These treatments aim to reduce esophageal hypercontractility, relax smooth muscle, decrease pain sensitivity, and improve symptoms like chest pain, dysphagia, and regurgitation, in line with guidelines for oesophageal manometry and oesophageal reflux monitoring 1.
Treatment Approach
Treatment typically begins with lifestyle modifications and medications before considering more invasive options like botulinum toxin injections or, in severe refractory cases, surgical myotomy, emphasizing the importance of a stepwise approach in managing these conditions.
From the Research
DCI and DL in Jackhammer Esophagus and Diffuse Esophageal Spasm
- In jackhammer esophagus, the DCI (distal contractile integral) is elevated, indicating hypercontractile peristalsis 2.
- The DL (distal latency) in jackhammer esophagus is often normal or slightly decreased 2.
- In diffuse esophageal spasm, the DCI may be normal or elevated, and the DL is often normal or slightly decreased 3, 2.
- Both conditions are characterized by abnormal esophageal motility, which can lead to symptoms such as dysphagia, chest pain, and gastroesophageal reflux.