This 78-year-old woman underwent an elective upper endoscopy following a one year history of dysphagia and intermittent chest pain. The following structure was visualized in the distal esophagus. What explains this phenomenon?

This anatomical spiral finding (red arrow) is called corkscrew esophagus, and is a classic finding of distal esophageal spasm (previously referred to as diffuse esophageal spasm). The typical clinical symptoms include chest pain, dysphagia or gastroesophageal reflux disease (GERD). The rare condition occurs predominately in elderly populations, therefore, sometimes it can be labeled as “presbyesophagus”, from the Greek word “presbys” meaning elderly, or aged. However, that term is now avoided as it implies that it is an expected, physiologic finding in older patients. 

Aging is frequently associated with deterioration of esophageal motility; a manometry study performed on subjects between the ages of 90 and 99 found that:

1. Only 51% of subjects had peristalsis following swallowing
   
2. Lower esophageal sphincter relaxation occured after only 44% of swallows
3. There was an increased rate of non-propulsive contractions

These uncoordinated efforts of the esophagus are the underlying driver of these esophageal changes seen on barium examination (A) and endoscopy (B).

Sources: SOERGEL KH, ZBORALSKE FF, AMBERG JR. PRESBYESOPHAGUS: ESOPHAGEAL MOTILITY IN NONAGENARIANS. J Clin Invest. 1964 Jul;43(7):1472-9. doi: 10.1172/JCI105023. PMID: 14192528; PMCID: PMC289623. Available from https://pubmed.ncbi.nlm.nih.gov/14192528/

F. Lin, C. Li, Z. Liu, L. Liu, Corkscrew esophagus, QJM: An International Journal of Medicine, Volume 110, Issue 5, May 2017, Page 325. Available from https://academic.oup.com/qjmed/article/110/5/325/2993113