From the Guidelines
The best medical treatment for esophageal spasm typically involves calcium channel blockers like nifedipine (10-30 mg daily) or diltiazem (30-90 mg daily), which help relax the smooth muscle of the esophagus. Nitrates such as isosorbide dinitrate (5-10 mg sublingually as needed) can also provide relief during acute episodes. For patients who don't respond to these medications, low-dose tricyclic antidepressants like amitriptyline (10-50 mg at bedtime) may help by reducing pain sensitivity. Proton pump inhibitors such as omeprazole (20-40 mg daily) are often added to the regimen since acid reflux can trigger or worsen spasms.
Treatment Considerations
- Treatment should be individualized and typically continues for several months, with dosage adjustments based on symptom control and side effects.
- Lifestyle modifications are also important, including avoiding trigger foods (spicy, acidic, very hot or cold items), eating smaller meals, and elevating the head of the bed.
- These medications work by either directly relaxing the esophageal muscles or by addressing underlying conditions that contribute to spasms, such as acid reflux or heightened pain perception.
Additional Therapies
- Per-oral endoscopic myotomy (POEM) may be considered for patients with type III achalasia, which is characterized by spastic body contractions capable of luminal obliteration, as it provides the advantage of unlimited proximal extension of myotomy 1.
- However, the evidence for POEM in nonachalasia spastic disorders, including esophageal spasm, is limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted 1.
From the Research
Medical Treatment Options for Esophageal Spasm
The best medical treatment for esophageal spasm is a topic of ongoing research and debate. According to various studies, the following treatment options have shown promise:
- Acid suppression, muscle relaxants, and visceral analgetics should be tried first 2
- Proton-pump inhibitors, nitrates, calcium-channel blockers, and tricyclic antidepressants or serotonin reuptake inhibitors have been documented to improve symptoms 2
- Botulinium toxin injections can be beneficial for patients who do not respond to initial treatments 2, 3
- Pneumatic dilatations or myotomies may be considered for non-responding patients, although these approaches are more invasive 2, 4
Diagnosis and Treatment Approach
Diagnosing esophageal spasm can be challenging due to its intermittent nature and similarity to other conditions. A comprehensive approach to diagnosis and treatment is essential:
- Manometry and barium studies can be used as complementary diagnostic approaches 5
- Treatment should begin with the least invasive intervention and progress to more invasive options as needed 5
- A management algorithm based on current available literature can help guide treatment decisions 6
Surgical Treatment Options
Surgical treatment may be considered for patients who do not respond to medical therapy: