Snapshot A 72-year-old obese woman presents to her primary care physician with intermittent chest pain and difficulty swallowing liquids and solid foods. Cardiac work up including electrocardiogram, cardiac enzymes, and coronary angiography is normal. She undergoes barium swallow radiography, which was normal. Further testing with esophageal manometry shows 182 mmHg of pressure created by the esophagus during peristalsis. Introduction Clinical definition high-amplitude but coordinated contraction of the esophagus, also known as hyperperistalsis benign and non-progressive Associated conditions metabolic syndrome obesity gastroesophageal reflux disease Epidemiology Any age but more common in 60-70s ETIOLOGY Pathogenesis causes are unclear may be related to dysregulated neurotransmitters or nitric oxide levels Presentation Symptoms asymptomatic chest pain (non- exertional) that may radiate to arm, back, neck, or jaw dysphagia to solid and liquid foods Physical exam no specific findings imaging Upper gastrointestinal barium swallow can be normal can have a spiral appearance Other studies esophageal manometry diagnostic peristaltic contractions with ≥ 180 mmHg amplitude endoscopy normal used to rule out anatomical causes of dysphagia Studies Diagnostic testing diagnostic approach can be difficult to distinguish from cardiac chest pain and cardiac work up such as electrocardiogram (EKG), stress test, and even coronary angiography is often indicated and normal Differential Achalasia distinguishing factor increased lower esophageal sphincter function Diffuse esophageal spasm distinguishing factor normal amplitude but non-peristaltic contractions Angina and acute coronary syndrome distinguishing factors cardiac risk factors ↑ cardiac enzymes ST changes on EKG Treatment Risk factor modification weight loss First-line calcium channel blockers and nitrates reduce the severity of spasm trazodone antidepressant reduce visceral sensitivity Interventional endoscopic injection of botulinum toxin endoscopic dilatation Heller myotomy indicated for cases refractory to other treatment relaxes the lower esophageal sphincter and myenteric plexus Complications Food bolus obstruction