Distal esophageal spasm and hypercontractile esophagus

Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.

GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.

Vasospastic (Prinzmetal) angina is angina from transient epicardial coronary artery spasm, causing rest chest pain with transient ST elevation, typically at night or in the early morning. Diagnosis rests on documenting spasm or reversible ST changes, and treatment is calcium channel blockers and nitrates while strictly avoiding non-selective beta-blockers and triggers.

Chest pain is a symptom, not a diagnosis, spanning cardiac, vascular, pulmonary, gastrointestinal, musculoskeletal, and psychiatric causes. The essential task is separating four do-not-miss diagnoses, acute coronary syndrome, aortic dissection, pulmonary embolism, and tension pneumothorax, from benign mimics with a structured history, an ECG within 10 minutes, and serial troponin, treating suspected acute coronary syndrome empirically with aspirin and nitroglycerin while the workup proceeds.

Eosinophilic esophagitis is a chronic, immune/antigen-mediated disease of the esophagus that presents with solid-food dysphagia and food impaction in young atopic men, diagnosed by endoscopic biopsy showing 15 or more eosinophils per high-power field after excluding other causes. Management follows the three D's: dietary elimination, drug therapy with a PPI and/or swallowed topical corticosteroids, and dilation for fibrostenotic strictures.

Systemic sclerosis is a multiorgan disease of vascular injury and progressive fibrosis in which diffuse cutaneous disease extends skin thickening proximal to the elbows and knees and drives early visceral fibrosis. Diagnosis rests on the 2013 ACR/EULAR classification criteria and an antibody split (anti-Scl-70, anticentromere, anti-RNA polymerase III), and treatment is organ-specific: mycophenolate or nintedanib for interstitial lung disease, calcium channel blockers for Raynaud phenomenon, and captopril for scleroderma renal crisis.

Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.

Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.