Diffuse esophageal spasm differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Madhu Sigdel M.B.B.S.[2]

Overview

DES must be differentiated from other diseases that cause chest pain and dysphagia, such as Angina, GERD, eosinophilic/infectious/radiation esophagitis, stricture/webs/rings as well as other motility disorders like nutcracker esophagus and hypertensive LES.

Differentiating DES from other Diseases

Disease	Signs & Symptoms	Findings on barium swallow	Endoscopy	Imaging test
Reflux esophagitis	Dysphagia (from peptic stricture) Heartburn Hoarseness	Poor clearance Free reflux of barium	peptic stricture (advanced cases)	A hiatus hernia may be present below the stricture Lower esophageal pH studies will demonstrate pathologic gastroesophageal reflux
Esophageal carcinoma	Dysphagia (initially for solids, liquids develops with advanced disease.) Weight loss Lymphadenopathy Appetite changes Cachexia	irregular stricture pre-stricture dilatation	Most accurate test for diagnosis esophageal obstruction staging of disease	Biopsy: for definite diagnosis and tumor histology
Systemic sclerosis	Dysphagia Muscle and joint pain Raynaud's phenomenon skin changes (e.g., rash, skin swelling or thickening).	Dysmotility Patulous esophagus	Mucosal damage Peptic stricture (advanced cases)	Serology for Antinuclear antibodies Rheumatoid factor creatine kinase ESR
Esophageal spasm	Chest pain (more prominent) Dysphagia (intermittent)	Corkscrew or rosary bead esophagus nonperistaltic contractions	Inconclusive	Manometry: high-amplitude esophageal contractions
Pseudoachalasia	Dysphagia Weight loss Lymphadenopathy Appetite changes Cachexia Older patients Underlying malignancy that mimics idiopathic achalasia. Patients tend to be older, duration of symptoms shorter, and weight loss greater and more rapid.	More marked mucosal irregularity Temporary patency of LES	Most accurate test for diagnosis esophageal obstruction staging of disease	Gastroscopic biopsy of gastroesophageal junction and cardia may demonstrate malignancy. Findings at endoscopy, barium swallow, and manometry may be indistinguishable from achalasia.
Chagas disease	Dysphagia myocarditis Blepharitis Toxic megacolon	oesophageal dilatation stasis of barium	dilated esophagus thickened LES (muscular ring)	Giemsa stain: Trypanosoma cruzi. PCR for trypanosome subtype
Pharyngitis	Dysphagia Fever Throat pain	Normal	Inconclusive	erythema, edema and/or exudates of the pharynx; tonsillar hypertrophy may cause severe narrowing of the pharynx; lymphadenopathy of the neck is often present
Esophageal candidiasis	Dysphagia Immunocompromised History of corticosteroid	shaggy" appearance (plaques) irregular contours in the lower third	ulceration plaques and pseudomembranes tiny nodules, polypoid folds (advanced cases)	creamy white or yellowish plaques (thrush) in oropharynx or hypopharynx; may be normal exam
Stroke	progressive Dysphagia; dysarthria; limb weakness Fatigue	pooling of contrast in the pharynx aspiration of the barium contrast into the airway.	reduced opening of upper esophageal sphincter reduced larynx elevation	paraplegia, aphasia, dysarthria, vertigo, staggering, diplopia, deafness

• DES must be differentiated from other diseases that cause chest pain, dysphagia and weight loss, such as , [differential dx2], and [differential dx3].