Snapshot A 49-year-old woman with depression and anxiety presents to the emergency room for chest pain. She reports that she was feeling well apart from intermittent difficulty swallowing. After her smoothie today, she experienced acute onset of retrosternal chest pain that radiated to her neck. She is worried that she is having a heart attack. Introduction Clinical definition non-peristaltic contractions of the esophagus that are simultaneous or uncoordinated Associated conditions gastroesophageal reflux disease depression and anxiety neuromuscular or neurodegenerative disorders Epidemiology Incidence likely underdiagnosed due to vague symptoms Demographs rare in children more common in women etiology Pathogenesis causes are unclear often precipitated by ingestion of hot or cold liquids possibly due to aberrant neurological signaling Presentation Symptoms chest pain (non-exertional) that may radiate to arm, back, neck, or jaw dysphagia globus Physical exam no specific findings imaging Upper gastrointestinal barium swallow “corkscrew” or “rosary bead esophagus” only during a spasm not specific to diffuse esophageal spasm 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 other studies esophageal manometry diagnostic shows normal lower esophageal sphincter and normal-amplitude, simultaneous contracts after a swallow endoscopy normal Differential Achalasia distinguishing factor increased lower esophageal sphincter function Nutcracker esophagus distinguishing factor coordinated but high amplitude contractions Angina and acute coronary syndrome distinguishing factors cardiac risk factors ↑ cardiac enzymes ST changes on EKG Treatment First-line calcium channel blockers and nitrates reduce the severity of spasm proton pump inhibitor treat associated reflux tricyclic antidepressant treat associated mood disorder Interventional endoscopic injection of botulinum toxin myotomy indicated for severe and incapacitating symptoms refractory to other treatment Complications Lack of response to treatment