What are the management options for esophageal spasms?

Management of Esophageal Spasms

Pharmacotherapy is the first-line treatment for esophageal spasms, beginning with proton pump inhibitors (PPIs) for 4-8 weeks, followed by smooth muscle relaxants and neuromodulators for refractory cases. 1

Diagnostic Approach

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

Treatment Algorithm

First-Line Treatment

1. Proton Pump Inhibitor (PPI) Therapy

   • Start with single-dose PPI therapy for 4-8 weeks 2, 1
   • If inadequate response, increase to twice daily dosing or switch to a more effective acid suppressive agent 2
   • Rationale: GERD frequently coexists with esophageal spasm and may contribute to symptoms 3

2. Smooth Muscle Relaxants

   • Calcium channel blockers (e.g., diltiazem)
     • May provide relief in selected individual patients 4
   • Nitrates (short and long-acting)
   • 5-phosphodiesterase inhibitors (e.g., sildenafil)
     • Case reports show improvement in oesophageal function and relief of dysphagia and chest pain 5

Second-Line Treatment

1. Neuromodulators

   • Low-dose antidepressants (tricyclic agents or SSRIs)
   • Particularly effective for visceral hypersensitivity and pain component 1
   • Consider for patients with esophageal hypervigilance or hypersensitivity

2. Endoscopic Botulinum Toxin Injection

   • For patients with refractory symptoms despite pharmacotherapy 6
   • Good symptomatic benefit reported in patients with diffuse esophageal spasm
   • Caution: Monitor for potential development of post-injection gastroesophageal reflux 3

Third-Line Treatment

1. Peroral Endoscopic Myotomy (POEM)

   • Emerging technique particularly effective for type III achalasia with spastic components 1
   • Allows for extended myotomy that can address the full length of spastic segments

2. Surgical Intervention

   • Heller myotomy (usually combined with fundoplication)
   • Reserved for very severe symptoms refractory to all other treatments 1, 3
   • Should only be considered after comprehensive evaluation and confirmation of diagnosis

Special Considerations

Achalasia Subtypes

• Type III achalasia (associated with persistent peristalsis with spasm) has the poorest response to all treatments compared to types I and II 2
• Treatment decisions should be based on local expertise, therapeutic availability, and patient choice rather than subtype 2

Adjunctive Therapies

• Consider alginate antacids for breakthrough symptoms
• Nighttime H2 receptor antagonists for nocturnal symptoms
• Baclofen for regurgitation or belch predominant symptoms 2

Behavioral Interventions

• Hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies may benefit patients with functional heartburn or reflux disease associated with esophageal hypervigilance and reflux hypersensitivity 2

Pitfalls and Caveats

1. Given the intermittent nature of esophageal spasm, it is difficult to rule out the condition completely 7
2. Manometry and barium studies should be considered complementary diagnostic approaches 7
3. Esophageal spasm can sometimes progress to achalasia, requiring ongoing monitoring 3
4. Avoid metoclopramide as monotherapy or adjunctive therapy in patients with esophageal syndromes (Grade D recommendation - fair evidence that it is ineffective or harms outweigh benefits) 2

Remember that treatment of esophageal spasms can be challenging, and a stepwise approach starting with the least invasive interventions is recommended.