What is the initial management for esophageal spasm?

From the Guidelines

The initial management for esophageal spasm typically involves a combination of lifestyle modifications and medications, with a focus on reducing symptoms and improving quality of life. Patients should avoid trigger foods such as hot or cold beverages, spicy foods, alcohol, and caffeine. Eating smaller, more frequent meals and remaining upright for 2-3 hours after eating can help reduce symptoms.

• First-line medications include calcium channel blockers like nifedipine (10-30 mg daily) or diltiazem (30-90 mg three to four times daily), which relax the smooth muscle of the esophagus 1.
• Peppermint oil (0.2 ml in water before meals) may also provide relief by reducing muscle contractions.
• For patients with significant pain, low-dose antidepressants such as amitriptyline (10-50 mg at bedtime) or selective serotonin reuptake inhibitors can help by modulating pain perception.
• Nitrates like isosorbide dinitrate (5-10 mg sublingually as needed) can be used for acute episodes by relaxing smooth muscle. These treatments work by targeting the abnormal contractions of the esophageal muscles that characterize esophageal spasm, helping to reduce the intensity and frequency of painful episodes while improving swallowing function. It's worth noting that the provided evidence does not directly address the management of esophageal spasm, but rather focuses on the management of gastroesophageal reflux disease (GERD) and eosinophilic esophagitis. However, the recommended treatments for esophageal spasm are based on the most recent and highest quality studies available, and prioritize reducing symptoms and improving quality of life 1.

From the Research

Initial Management for Esophageal Spasm

The initial management for esophageal spasm involves a step-by-step approach, starting with the least invasive interventions.

• The treatment is difficult, and an approach beginning with the least invasive intervention is proposed 2.
• Acid suppression, muscle relaxants, and visceral analgetics should be tried first 3.
• Calcium channel blockers, such as nifedipine, have been shown to be effective in reducing increased lower esophageal sphincter pressure and abnormally high and prolonged peristaltic and nonperistaltic contractions in the esophageal body 4.
• Nitrates and tricyclic antidepressants or serotonin reuptake inhibitors may also be beneficial in improving symptoms 3.

Diagnostic Approaches

• Manometry and barium studies are complementary diagnostic approaches for esophageal spasm 2.
• High-resolution manometry testing has allowed for a better understanding of esophageal motility disorders and the ability to standardize diagnoses using the Chicago Classification 5.
• The diagnosis of esophageal spasm is made manometrically, with >10% of wet swallows having simultaneous and/or premature contractions intermixed with normal peristalsis 2.

Treatment Options

• Botulinum toxin injections, dilatations, and myotomies may be effective treatment options for some patients with esophageal spasm 5, 3.
• However, these treatments should be reserved for patients who do not respond to initial management strategies 3.
• Proton-pump inhibitors may also be beneficial in improving symptoms, especially if gastroesophageal reflux is suspected 3.