We'll move on to our next case.
We have a 48-year-old woman who presents
to the emergency department complaining of sudden intermittent episodes of severe chest pain.
She also notes difficulty with swallowing both liquids and solids when these episodes occur.
She has no known medical conditions and no family history of cardiac disease. Her vitals are normal.
On exam, oropharynx and cardiac exam are also normal.
So what is the best test to confirm the diagnosis?
So let's point out some key features of this case.
She has sudden onset chest pain that may mimic cardiac angina.
In addition, she has difficulty swallowing both solids and liquids.
So let's talk a bit about this diagnosis of diffuse esophageal spasm.
This is a hypertonic motility disorder where the esophagus just contracts too much.
They may present with chest pain that mimics cardiac angina
and they have dysphagia to both liquids and solids during these episodes.
To diagnose this you may do have barium swallow study which may show the typical appearance of a corkscrew esophagus.
However, the diagnosis is best made by esophageal manometry
which will show these high-amplitude contractions throughout the esophagus.
Here you can see a normal esophageal manometry test where contraction occurs along the length of the esophagus with peristalsis.
Here, this is a manometry showing a hypercontractile esophagus.
So a patient who has esophageal spasm may have too much contraction along the length of the esophagus as shown here.
The treatment is done with symptomatic relief.
You may give calcium channel blockers or botulinum toxin injections.
So now let's return to our case.
We have a 48-year-old woman presenting with sudden onset pain that mimics cardiac angina.
And her difficulty with swallowing both solids and liquids indicates an underlying motility disorder.
So all of these things combines should prompt you to think about diffuse esophageal spasm.
And the best test to diagnose it is with esophageal manometry.
You might have thought about a barium swallow study but this may be falsely normal if an episode is not occurring at the time of the test.