{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 2, Ep 2 of 2: Spasm, Scleroderma, and EGJOO","html":"","width":"100%","height":180,"duration":1417,"description":"The normal-IRP side of the Chicago algorithm covers everything that is not achalasia or EGJOO. The\nsphincter relaxes; the question shifts to what the body is doing. Distal esophageal spasm is a\ntiming problem (premature contraction). Hypercontractile esophagus is a vigor problem (DCI above\n8000). Ineffective motility and absent contractility sit at the failed end. Scleroderma is the\none disorder that breaks the rule, presenting as absent contractility plus a hypotensive LES that\nlets reflux through. And EGJOO is the elevated-IRP-with-preserved-peristalsis bucket that v4.0 made\nharder to call on purpose, because v3.0 was overcalling it.\n \nThe case. A patient with chest pain and intermittent dysphagia. Cardiac workup is negative. Manometry shows\na normal IRP, 30% of swallows with a distal latency of 3.8 seconds, and a normal DCI on the rest.\nWhat is the diagnosis, and what is the first treatment move?\n \nTopics covered\n\nIRP as the sorter: elevated IRP routes to achalasia or EGJOO; normal IRP opens the body branch\nDistal esophageal spasm: ≥20% premature swallows (DL under 4.5s) on a normal IRP, in a symptomatic patient\nHypercontractile (jackhammer) esophagus: ≥20% of swallows with DCI above 8000, in a symptomatic patient\nWhy distal latency captures spasm and contraction front velocity does not: deglutitive inhibition vs raw wave speed\nSpasm treatment ladder: address contributors first (opioids, GERD, EoE), then calcium channel blockers, nitrates, sildenafil, peppermint oil, neuromodulators\nType 3 achalasia vs spasm: same body pattern, different IRP, and POEM vs medical therapy follows\nScleroderma esophagus: absent contractility plus hypotensive LES as a dual hit; Nissen contraindicated, partial wrap or no wrap\nIneffective esophageal motility (IEM): more than 70% ineffective or at least 50% failed swallows; surgical implications for fundoplication planning\nEGJ outflow obstruction: v4.0 requires both supine and upright IRP elevation, intrabolus pressurization,...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}