From the Guidelines
Esophageal spasm treatment should prioritize a personalized approach, incorporating lifestyle modifications, medications, and alternative therapies to manage symptoms and improve quality of life. The treatment of esophageal spasm typically begins with lifestyle modifications, such as avoiding trigger foods like spicy or acidic items, eating smaller meals, and remaining upright for 2-3 hours after eating. First-line medications may include proton pump inhibitors (PPIs) or calcium channel blockers to reduce acid reflux and relax the esophageal muscles, respectively. However, the most recent evidence suggests that alternative treatment methods, such as lifestyle modifications, alginate-containing antacids, external upper esophageal sphincter compression device, cognitive-behavioral therapy, and neuromodulators, may serve a role in management of esophageal spasm symptoms 1. Additionally, low-dose antidepressants, such as amitriptyline, may be used to modulate pain perception, and botulinum toxin injections into the lower esophageal sphincter may provide relief for 3-6 months. In severe cases unresponsive to medical therapy, surgical myotomy or peroral endoscopic myotomy (POEM) may be considered to physically divide the muscle fibers causing the spasms. The use of neuromodulation with low-dose anti-depressants and behavioral interventions, such as cognitive-behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing, may also be beneficial in patients with esophageal hypervigilance, reflux hypersensitivity, and/or behavioral disorders 1. Key considerations in the treatment of esophageal spasm include:
- Reducing acid exposure that triggers spasms
- Directly relaxing smooth muscle in the esophagus
- Altering pain perception pathways
- Addressing underlying mechanisms, such as esophageal hypersensitivity and hypervigilance
- Utilizing alternative therapies, such as cognitive-behavioral therapy and neuromodulators, to manage symptoms and improve quality of life.
From the Research
Treatment Options for Diffuse Esophageal Spasm
The treatment for diffuse esophageal spasm is difficult and various approaches have been proposed. Some of the treatment options include:
- Medical treatment with agents that reduce esophageal contractile force, such as anticholinergic agents, nitrates, and calcium antagonists 2
- Calcium channel antagonists, alone or in combination with anticholinergics or nitrates, can be used as a medical trial, especially in mild cases 2
- Centrally acting drugs, such as benzodiazepines or antidepressants, may also be beneficial in some patients 2
- Relaxation training and double swallowing have been shown to be effective in reducing painful esophageal spasms and improving psychological state in some patients 3
- Surgical treatment, including long esophageal myotomy and antireflux procedure, may be considered for patients who do not respond to medical therapy 4
Rationale for Treatment
The rationale for treatment is based on the underlying pathophysiology of the disorder, which is characterized by simultaneous contractions in the distal esophagus and normal peristalsis 5, 6. The use of agents that reduce esophageal contractile force, such as calcium channel antagonists, can help to alleviate symptoms in some patients 2. Additionally, relaxation training and double swallowing can help patients cope with disordered esophageal motility 3.
Surgical Treatment
Surgical treatment for diffuse esophageal spasm is based on similar principles to the treatment of achalasia, and involves a long esophageal myotomy to divide the hypertrophied circular muscle 4. An antireflux procedure may also be added to protect against postoperative reflux. However, the surgical treatment of diffuse esophageal spasm has not been subjected to randomized clinical trials, and the optimal treatment remains controversial 4.