A 60-year-old man presented with a six-month history of episodes of a "knotlike feeling" in the epigastrium associated with flushing, ill-defined chest pains, and shortness of breath. The episodes lasted several hours and were not associated with exertion. None of the episodes occurred during meals, but some were associated with lying down after meals. Sublingual nitroglycerin gave some relief. There was no heartburn or dysphagia. Previous evaluation at another institution had included a resting electrocardiogram, an echocardiogram, Holter monitoring, a thallium stress test, coronary angiography, barium swallow, an oral cholecystogram, and upper gastrointestinal tract endoscopy, all of which were normal. The results of physical examination were normal except for obesity. Results of esophageal manometry were grossly abnormal. There were contraction abnormalities in the distal body with waves of increased amplitude and duration and repetitive waves but no triple-peaked waves (Figure). Acid infusion did not induce chest pain.
William F. Stenson,