What are the clinical manifestations of an esophageal spasm?

Clinical Manifestations of Esophageal Spasm

Esophageal spasm typically presents with two cardinal symptoms: non-cardiac chest pain and dysphagia, with chest pain being the most common presenting complaint, though the clinical presentation can be highly variable and symptoms may be intermittent. 1, 2, 3

Primary Symptoms

Chest Pain

• Non-cardiac chest pain is the predominant symptom, occurring in approximately 29% of patients as their leading complaint 3
• The pain can mimic cardiac ischemia and may present as a squeezing or burning sensation 4
• Pain often occurs after meals or at night and can worsen with stress 4
• The chest discomfort is typically retrosternal and can be severe enough to prompt cardiac evaluation 1, 2

Dysphagia

• Dysphagia is the most frequent leading symptom, occurring in approximately 51% of patients 3
• The dysphagia is characteristically non-obstructive in nature 2
• Patients may experience difficulty swallowing both solids and liquids, distinguishing it from mechanical obstruction 1, 5

Associated Symptoms

• Weight loss occurs in approximately 26% of patients, likely secondary to dysphagia and dietary modifications 3
• Odynophagia (painful swallowing) may be present 1
• Regurgitation can occur in some patients 1

Clinical Characteristics and Diagnostic Challenges

Intermittent Nature

• The disorder is characterized by intermittent symptoms, making diagnosis challenging - simultaneous contractions occur intermixed with normal peristalsis 2, 5
• Given this intermittent nature, it is almost impossible to completely rule out spasm on a single diagnostic test 2

Delayed Diagnosis

• There is typically a significant delay from symptom onset to diagnosis, with a median time of 48 months from symptom onset and 8 months from first medical consultation to diagnosis 3
• This delay reflects the clinical heterogeneity and intermittent nature of the disorder 3

Important Clinical Associations

Gastroesophageal Reflux Disease (GERD)

• GERD frequently coexists with esophageal spasm, being diagnosed in approximately 38% of patients 3
• GERD should be investigated or treated first, as simultaneous contractions may result from gastroesophageal reflux 1, 5

Medication-Related Causes

• Esophageal spasm may be secondary to medications, especially opiates 6
• A systematic search for medications that might promote esophageal dysmotility should be performed 6

Comorbidities

• Hypertension and psychiatric problems (anxiety, depression) are the most frequent comorbidities 3
• Many patients are already taking acid-reducing medications (75%) and psychotropic drugs (45%) at presentation 3

Physical Examination

• Physical examination is typically unremarkable and non-specific 1
• No pathognomonic physical findings exist for esophageal spasm 1

Critical Pitfall to Avoid

The most important clinical consideration is that cardiac causes must be ruled out first, as the morbidity and mortality associated with ischemic heart disease is substantially greater than that of esophageal disorders 4. Failing to adequately exclude cardiac causes before attributing chest pain to esophageal origin can lead to catastrophic misdiagnosis 4.