Where the Jackhammer Meets the Corkscrew: A Case of Manometric Hypercontractile Esophagus and Esophagogastric Junction Outflow Obstruction With Endoscopic Features of Distal Esophageal Spasm

CASE REPORT A 70-year-old woman with Parkinson disease and diabetes mellitus with a 3-month history of intermittent solid food dysphagia and heartburn underwent barium esophagraphy, revealing tertiary contractions in the mid-to-distal esophagus (Figure 1). Esophagogastroduodenoscopy (EGD) with pH monitoring showed no structural abnormalities and normal acid exposure. High-resolution manometry revealed median integrated relaxation pressure 32.0 mm Hg, 0% premature contractions, 0% intact contractions, and 40% hypercontractile swallows (Figure 2); integrated relaxation pressure elevation persisted during upright swallows, and rapid drink challenge maneuver revealed pressurization. Repeat EGD with Endoflip demonstrated extraesophageal peristaltic contractions producing a classic “corkscrew” (Figure 3) and a distensibility of 1.1 mm2/mm Hg with maximum observed diameter of 10 mm. Diagnosed with hypercontractile esophagus with esophagogastric junction outflow obstruction, she was prescribed calcium channel blockers and referred for per-oral endoscopic myotomy.Figure 1.: Barium esophagram showing moderate tertiary contractions of the mid-to-distal esophagus.Figure 2.: High-resolution manometry composite of 10 swallows showing hypercontractile swallows and elevated lower esophageal sphincter pressures.Figure 3.: Endoscopic image of the distal esophagus showing spastic contractions in a characteristic “corkscrew” pattern.While distal esophageal spasm typically produces “corkscrew” appearance on barium esophagram and EGD, these findings are uncommon in hypercontractile esophagus.1–3 Note is made of our patient's history of Parkinson disease, which encompasses manometric findings of several esophageal motility disorders from aperistalsis to distal esophageal spasm and esophagogastric junction outflow obstruction.4 This case highlights the importance of integrating clinical, endoscopic, and manometric findings to tailor management of esophageal dysmotility. DISCLOSURES Author contributions: All authors contributed equally to the writing and review of this image case report, from acquiring patient data during chart review to drafting the case report and critically reviewing it prior to publication. I. Inayat provided endoscopic images, interpreted manometric data and commented on the clinical novelty of the case. M. Naveed, E. Gonzaga and N. Khan contributed to the writing of the initial draft, final manuscript and subsequent revisions. The final draft was read and approved by all authors. All authors agree to accept accountability for the case report and questions related to it. ES Robalino Gonzaga is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.