What are the treatment options for esophageal spasms?

Treatment of Esophageal Spasms

The treatment of esophageal spasms should follow a stepwise approach, beginning with pharmacotherapy including smooth muscle relaxants, proton pump inhibitors, and neuromodulators, followed by endoscopic botulinum toxin injection for refractory cases, and surgical interventions as a last resort for severe cases unresponsive to other treatments.

Pharmacologic Therapy

First-Line Options

• Smooth Muscle Relaxants:

  • Calcium channel blockers (e.g., nifedipine, diltiazem)
  • Nitrates (short and long-acting)
  • These medications reduce esophageal contractile force and can provide symptomatic relief 1

• Proton Pump Inhibitors (PPIs):

  • 4-8 week trial of single-dose PPI therapy
  • May be increased to twice daily if inadequate response
  • Particularly important as GERD frequently coexists with esophageal spasm and may contribute to symptoms 2, 3

• Anticholinergic Agents:

  • Can be used to reduce esophageal contractility
  • Often combined with calcium channel blockers for enhanced effect 1

Second-Line Options

• Neuromodulators:

  • Low-dose antidepressants (tricyclic agents or SSRIs)
  • Particularly useful for visceral hypersensitivity and pain component 4
  • Consider for patients with esophageal hypervigilance or hypersensitivity 2

• Baclofen:

  • Can be beneficial for regurgitation or belch-predominant symptoms
  • Acts by inhibiting transient lower esophageal sphincter relaxations 5

Endoscopic Interventions

Botulinum Toxin Injection

• Most well-studied endoscopic treatment option for diffuse esophageal spasm 6
• Technique:
  • 100 IU BTX diluted in 10 mL saline solution
  • Injected at multiple sites along the esophageal wall
  • Starting at lower esophageal sphincter and moving proximally at 1-1.5 cm intervals 7
• Efficacy:
  • Provides good symptomatic benefit in 78-89% of patients
  • Effects can last 6-24 months before reinjection may be needed 7
  • Symptom relapse can be effectively treated with repeated injections 7

Surgical and Advanced Interventions

Per Oral Endoscopic Myotomy (POEM)

• Emerging technique that may be beneficial for esophageal spasm
• Particularly effective for type III achalasia which has spastic components 2
• Allows for extended myotomy that can address the full length of spastic segments 2

Surgical Myotomy

• Heller myotomy (usually combined with fundoplication)
• Reserved for very severe symptoms refractory to pharmacologic and endoscopic treatment 3
• Should only be considered after comprehensive evaluation and confirmation of diagnosis 2

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders
• Endoscopy to rule out structural abnormalities and assess for erosive esophagitis
• Consider pH monitoring to evaluate for concomitant GERD 2

Treatment Algorithm

1. Initial Management:

   • Trial of PPI therapy (4-8 weeks)
   • Calcium channel blockers or nitrates
   • Lifestyle modifications if GERD is present

2. If inadequate response:

   • Increase PPI to twice daily
   • Add neuromodulators
   • Consider combination therapy with multiple smooth muscle relaxants

3. For persistent symptoms:

   • Consider endoscopic botulinum toxin injection
   • Evaluate response after 4 weeks

4. For refractory cases:

   • Consider POEM or surgical myotomy
   • Referral to specialized centers with expertise in esophageal motility disorders

Common Pitfalls and Caveats

• Misdiagnosis of esophageal spasm as cardiac chest pain or vice versa
• Failure to identify and treat coexisting GERD, which can exacerbate symptoms
• Inadequate duration of pharmacologic therapy before declaring treatment failure
• Overuse of invasive interventions before optimizing medical management
• Failure to recognize that some patients may require combination therapy rather than monotherapy

The clinical response to pharmacologic therapy for esophageal spasm is often suboptimal despite good manometric response, highlighting the need for a comprehensive approach that may include endoscopic or surgical interventions for refractory cases 1.