What is the treatment for esophageal spasms?

Treatment for Esophageal Spasms

The most effective treatment for esophageal spasms is a stepwise approach starting with pharmacologic therapy, followed by endoscopic interventions for refractory cases, with Per-Oral Endoscopic Myotomy (POEM) reserved for severe cases that fail conservative management. 1

Initial Pharmacologic Management

First-line medications:

• Smooth muscle relaxants:
  • Calcium channel blockers (e.g., nifedipine)
  • Nitrates (e.g., isosorbide dinitrate)
  • Consider long-acting nitrates for maintenance therapy in patients without gastroesophageal reflux 2

Second-line medications:

• Phosphodiesterase-5 inhibitors:
  • Sildenafil (25-50mg twice daily) has shown efficacy in treatment-resistant cases by reducing peristaltic pressure and velocity 3
• Acid suppression therapy:
  • Proton pump inhibitors when reflux symptoms coexist with spasms

Endoscopic Interventions

Botulinum toxin injection:

• Indicated when pharmacologic therapy fails
• Technique: 100 IU diluted in 10mL saline solution injected at multiple sites along the esophageal wall
• Begin at the lower esophageal sphincter and move proximally in 1-1.5cm intervals
• Target endoscopically visible contraction rings
• Efficacy: 78-89% of patients show immediate improvement after one session 4
• Duration: Effects typically last 6-24 months; retreatment is effective for symptom recurrence

Endoscopic dilation:

• Consider for patients with associated strictures or narrow-caliber esophagus
• Particularly useful for patients with obstructive symptoms 5

Advanced Interventions for Refractory Cases

Per-Oral Endoscopic Myotomy (POEM):

• First-line treatment for severe, refractory cases, especially Type III achalasia with spastic features 1
• Advantages:
  • Allows unlimited proximal extension of myotomy to address spastic segments
  • Tailored to the proximal extent of esophageal body spasm
  • More effective than limited lower esophageal sphincter myotomy 5
• Patient selection:
  • Should only be considered after comprehensive evaluation with correlation of symptoms
  • Reserved for cases where less invasive approaches have been exhausted 5

Surgical options:

• Extended myotomy (Heller procedure)
• Reserved for patients with severe symptoms refractory to all other treatments

Treatment Algorithm

1. Confirm diagnosis with high-resolution manometry and/or barium esophagram
2. Start with pharmacologic therapy:
   • Trial of smooth muscle relaxants for 4-8 weeks
   • Add PPI if reflux symptoms are present
   • Consider sildenafil for refractory cases
3. If symptoms persist, proceed to endoscopic therapy:
   • Botulinum toxin injection
   • Reassess after 4 weeks
   • Repeat injection if symptoms recur (effective for multiple treatments)
4. For severe refractory cases:
   • Comprehensive evaluation to confirm diagnosis
   • Consider POEM with extended myotomy tailored to the extent of spasm
   • Surgical myotomy as last resort

Monitoring and Follow-up

• Assess symptom response after 4-8 weeks of pharmacologic therapy
• For botulinum toxin treatment, follow-up at 1 month and 6 months
• After POEM or surgical intervention, follow-up at 1,3, and 12 months

Potential Pitfalls

• Inappropriate patient selection for invasive procedures
• Failure to distinguish between different types of esophageal motility disorders
• Inadequate treatment of coexisting conditions (especially GERD)
• Proceeding to invasive treatments without adequate trials of conservative management