What is the initial treatment for esophageal spasms?

Initial Treatment for Esophageal Spasms

The initial treatment for esophageal spasms should be smooth muscle relaxants such as calcium channel blockers or nitrates, along with proton pump inhibitors to address any underlying GERD that may be contributing to symptoms. 1

Pharmacological Management

First-line Therapy

• Smooth muscle relaxants:

  • Calcium channel blockers (e.g., diltiazem 60mg three times daily)
  • Long-acting nitrates for maintenance therapy in patients without GERD
  • These medications help relax the esophageal smooth muscle and reduce spastic contractions 1, 2

• Proton Pump Inhibitors (PPIs):

  • Should be prescribed concurrently as GERD frequently coexists with esophageal spasm
  • PPIs help reduce acid reflux that may trigger or worsen spasms 2, 3

Second-line Pharmacological Options

• Phosphodiesterase-5 inhibitors (e.g., sildenafil) for treatment-resistant cases
• Visceral analgesics (tricyclic antidepressants or SSRIs) to help manage pain associated with spasms 1

Endoscopic Interventions (for medication failures)

Botulinum Toxin Injection

• Consider when pharmacologic therapy fails
• Technique:
  • 100 IU diluted in 10mL saline solution
  • Injected at multiple sites along the esophageal wall
  • Begin at 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 1, 4
• Benefits can last 6-24 months, and reinjection is effective for symptom recurrence 4

Endoscopic Dilatation

• Useful for patients with associated strictures or narrow-caliber esophagus
• Particularly effective for acute symptoms such as food bolus obstruction 3, 1

Advanced Interventions (for refractory cases)

Per-Oral Endoscopic Myotomy (POEM)

• Reserved for severe, refractory cases, especially Type III achalasia with spastic features
• Advantages include unlimited proximal extension of myotomy to address spastic segments 1
• Only consider after comprehensive evaluation and failure of less invasive approaches

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis with manometry (normal peristalsis intermittently interrupted by simultaneous contractions)
   • Rule out other causes of similar symptoms (GERD, eosinophilic esophagitis)

2. First-line Treatment:

   • Start calcium channel blocker or nitrate + PPI
   • Assess response after 4-8 weeks

3. If inadequate response:

   • Consider adding or switching to phosphodiesterase-5 inhibitor or antidepressant
   • If still inadequate, proceed to endoscopic therapy

4. Endoscopic Therapy:

   • Botulinum toxin injection as first endoscopic intervention
   • For patients with strictures, consider dilatation

5. For Refractory Cases:

   • Consider POEM or surgical myotomy with fundoplication

Important Considerations and Pitfalls

• Individual response to calcium channel blockers can vary significantly; while studies show mixed overall results, they can provide relief in selected patients 5
• Botulinum toxin injection has better documented efficacy than pharmacological therapy alone 4
• Avoid proceeding to invasive treatments without adequate trials of conservative management 1
• Always assess for and treat coexisting conditions, especially GERD, which can exacerbate symptoms 2
• Monitor for side effects of calcium channel blockers (hypotension, headache, peripheral edema)

By following this approach, most patients with esophageal spasms can achieve significant symptom relief with pharmacological management, reserving more invasive procedures for truly refractory cases.