Interesting Findings of High-resolution Manometry Before and After Treatment in a Case of Diffuse Esophageal Spasm.

A 45-year-old woman visited the clinic presenting with squeezing chest pain during or after meal for 2 weeks. The findings of her esophagogastroduodenoscopy were unremarkable. Upon suspicion of non-erosive reflux disease, a proton pump inhibitor (pantoprazole 40 mg) had been prescribed to her, however her symptom was not relieved. She then was admitted to the hospital. To exclude coronary heart disease, cardiac tests including electrocardiography and echocardiography were performed, but no abnormality was found. To investigate esophageal motility disorder, high-resolution manometry (HRM) was performed, which revealed normal integrated relaxation pressure in 30% of swallows with reduced distal latency (DL, < 4.5 sec) and increased distal contractile integral (DCI) (Table and Figure A). Diffuse esophageal spasm (DES) was diagnosed and diltiazem (180 mg) was additionally prescribed to her. After 10 days of treatment, her symptom was moderately relieved and the short-term follow-up HRM showed slightly improved DL and decreased DCI (Figure B). After 90 days, her symptom disappeared and HRM findings completely were normalized (Figure C).

Table

The Change of Symptoms and Manometry Findings Before and After Treatment

aVisual analogue scale, bReduced distal latency: < 4.5 sec.

Figure

Serial changes of high-resolution manometry findings. (A) Before treatment, baseline findings show normal integrated relaxation pressure but reduced distal latency (DL) and increased distal contractile integral (DCI), which are suggestive of diffuse esophageal spasm. (B) Ten days after treatment, reduced DL and DCI are noted. (C) After 90 days, normalized DL and DCI are noted.

According to the Chicago classification, DES is defined as normal mean integrated relaxation pressure and ≥ 20% of swallows with reduced DL (< 4.5 sec).1 There are no large longitudinal studies of natural history in patients with DES. One small prospective study has reported that during long-term follow-up, the manometric findings of DES patients changed very little and the intensity of symptoms reduced.2,3 It suggests that acid suppression and smooth muscle relaxation are effective in some patients with DES.2 Herein is an interesting case of DES, in which both HRM features and symptoms responded to proton pump inhibitor and calcium channel blocker.