What are the treatment options for esophageal spasms?

Treatment Options for Esophageal Spasms

The primary treatment options for esophageal spasms include pharmacologic therapy with smooth muscle relaxants, endoscopic interventions such as botulinum toxin injections, and surgical procedures like POEM, with the specific approach determined by spasm subtype and symptom severity.

Diagnostic Classification

Before initiating treatment, proper classification of the esophageal spasm is essential:

• Diffuse Esophageal Spasm (DES): Defined by the presence of at least two premature contractions (distal latency <4.5 seconds) with normal EGJ relaxation 1
• Achalasia Type III: Characterized by spastic contractions with impaired lower esophageal sphincter relaxation 2
• Hypercontractile Esophagus: Excessive contractile vigor in the esophageal body

First-Line Pharmacologic Therapy

For mild to moderate symptoms, medication should be tried first:

• Calcium Channel Blockers:

  • Diltiazem (60 mg three times daily) can provide relief in selected patients with diffuse esophageal spasm 3
  • Effective in reducing esophageal contractile force, though clinical benefit may be limited 4

• Nitrates:

  • Short and long-acting formulations can help reduce smooth muscle contraction
  • Often used in combination with calcium channel blockers for enhanced effect 4

• PDE-5 Inhibitors:

  • Sildenafil (25-50 mg twice daily) has shown promise in treatment-resistant cases
  • Can normalize motility and relieve symptoms by suppressing excessive contractions 5

• Anticholinergic Agents:

  • May be used to reduce esophageal contractility
  • Often combined with other agents for enhanced effect 4

Endoscopic Interventions

For patients with inadequate response to medications:

• Botulinum Toxin Injection:

  • Highly effective for symptom relief in diffuse esophageal spasm
  • Technique: 100 IU BTX diluted in 10 mL saline, injected at multiple sites along the esophageal wall
  • Provides symptom relief in up to 89% of patients at 1 month 6
  • Effects may last 6-24 months; retreatment is effective for symptom recurrence 6

• Endoscopic Dilatation:

  • Useful for patients with associated strictures or narrow-caliber esophagus
  • Can be performed using balloon or bougie dilators 2

Advanced Interventional Options

For severe, refractory cases:

• Per-Oral Endoscopic Myotomy (POEM):

  • First-line treatment for Type III achalasia 2
  • Allows unlimited proximal extension of myotomy to address spastic segments 2
  • Superior to other interventions for spastic disorders of the esophagus

• Laparoscopic Heller Myotomy:

  • Combined with fundoplication
  • Consider for refractory cases, though POEM is generally preferred for spastic disorders 1

Treatment Algorithm Based on Spasm Type

For Diffuse Esophageal Spasm:

1. Start with calcium channel blockers (diltiazem 60mg TID) or nitrates
2. If inadequate response after 4-8 weeks, consider adding or switching to PDE-5 inhibitors
3. For persistent symptoms, proceed to botulinum toxin injection
4. For refractory cases, consider POEM

For Type III Achalasia:

1. POEM should be considered the preferred treatment 2
2. Extended myotomy tailored to the proximal extent of esophageal body spasm

For Non-Achalasia Spastic Disorders:

1. Comprehensive evaluation with correlation of symptoms is essential
2. Consider less invasive approaches before proceeding to POEM
3. POEM should only be considered on a case-by-case basis after other approaches have been exhausted 2

Monitoring and Follow-up

• Assess symptom response after 4-8 weeks of pharmacologic therapy
• For botulinum toxin injection, follow-up at 1 month and 6 months to assess response
• Consider retreatment with botulinum toxin for symptom recurrence

Common Pitfalls

• Misdiagnosis: Ensure proper diagnosis with high-resolution manometry before initiating treatment
• Inadequate treatment duration: Allow sufficient time (4-8 weeks) for pharmacologic therapy to take effect
• Overlooking GERD: Gastroesophageal reflux frequently coexists with esophageal spasm and may contribute to symptoms 1
• Failure to consider psychological factors: Consider visceral analgesics (tricyclic agents or SSRIs) when psychological components are present 4
• Inappropriate patient selection for invasive procedures: Ensure comprehensive evaluation before proceeding to POEM or surgical interventions 2