Transition from Diffuse Esophageal Spasm to Vigorous Achalasia

Abstract

A 72-year-old man was hospitalized with severe dysphagia and weight loss (6 kg/2 months) . Occasional dysphagia had occurred since about 20 years of age. He had been diagnosed with diffuse esophageal spasm (DES) 5 years earlier and was followed. Since July 1995, dysphagia became aggravate and prevented food intake.
On endoscopy, the cause of severe dysphagia was unclear. Radiological findings showed segmental contraction and a pool of mucus. On conventional esophageal manometry, basal lower esophageal sphincter (LES) pressure was 28 mmHg, and LES relaxation on swallowing was incomplete. Basal esophageal body pressure was higher than intragastric pressure. Swallowing 5 ml of water showed repetitive simultaneous contraction. The mean amplitude of simultaneous contraction was 40-60 mmHg.
These findings are characteristic of both achalasia, and DES and we diagnosed vigorous achalasia. The pathogenesis of vigorous achalasia is unclear. In this case, the possibility is that there was a transition from DES to achalasia. We consider that this case is valuable in the elucidation of the pathophysiology of vigorous achalasia.
Regarding treatment, oral nifedipine (10 mg) was not effective so we performed pneumatic dilatation. After pneumatic dilatation, symptoms disappeared entirely.