American College of Physicians: Internal Medicine — Doctors for Adults ®

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MKSAP Quiz: 2-year history of chest pain

From the February ACP Internist, copyright 2013 by the American College of Physicians

A 35-year-old man is evaluated for a 2-year history of intermittent chest pain. The pain is retrosternal, lasts for seconds to minutes, is unrelated to exertion, and does not radiate. It is occasionally associated with swallowing. He reports intermittent dysphagia to solids and liquids. He denies any reflux symptoms or weight loss. He does not have any risk factors for cardiac disease.

Physical examination is unremarkable. Upper endoscopy is normal. A barium swallow is shown.

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Which of the following is the most likely diagnosis?

A: Achalasia

B: Diffuse esophageal spasm

C: Eosinophilic esophagitis

D: Schatzki ring

Answer and Critique

The correct answer is B: Diffuse esophageal spasm. This question can be found in MKSAP 16 in the Gastroenterology and Hepatology section, item 14.

This patient has diffuse esophageal spasm. His symptoms (dysphagia to both solids and liquids) are suggestive of an esophageal dysmotility disorder. The differential diagnosis includes disorders like achalasia and diffuse esophageal spasm. Both may be associated with chest pain. Findings of a “corkscrew esophagus” (caused by multiple simultaneous contractions) on barium swallow are typical of diffuse esophageal spasm. Multiple simultaneous contractions are also seen on manometry. Treatment is usually initiated with calcium channel blockers.

On barium radiography, achalasia is characterized by esophageal dilatation with the classic “bird’s beak” appearance distally and the to-and-fro movement of barium (loss of peristalsis).

The diagnosis of eosinophilic esophagitis is made endoscopically and is characterized by multiple rings or esophageal strictures and increased mucosal friability, none of which are present in this patient.

A Schatzki ring is characterized by an isolated ring at the gastroesophageal junction that causes intermittent dysphagia. It is usually not associated with chest pain.

Key Point
  • Findings of a “corkscrew esophagus” (caused by multiple simultaneous contractions) on barium swallow are typical of diffuse esophageal spasm.

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