What is the treatment for esophageal spasms?

Treatment for Esophageal Spasms

The primary treatment for esophageal spasms includes a combination of endoscopic dilatation, pharmacotherapy with smooth muscle relaxants, and lifestyle modifications, with the specific approach determined by the type and severity of spasm.

Diagnostic Evaluation

Before initiating treatment, proper diagnosis is essential:

• High-resolution manometry (HRM) to differentiate between types of esophageal motility disorders
• Functional luminal impedance planimetry (FLIP) as an adjunct test to confirm findings
• Upper GI endoscopy to rule out structural abnormalities
• Barium swallow to assess esophageal function
• pH studies to evaluate for concurrent GERD

Treatment Algorithm

First-Line Treatments

1. Pharmacological Therapy:

   • Calcium channel blockers (e.g., diltiazem 60mg three times daily) 1
   • Nitrates for acute symptom relief
   • Proton pump inhibitors if GERD is present or suspected
   • Anticholinergic agents as alternative smooth muscle relaxants 2

2. Endoscopic Dilatation:

   • Indicated for patients with acute symptoms such as food bolus obstruction and daily dysphagia 3
   • Particularly effective for patients with established tight stricture or narrow caliber esophagus 3
   • Can be repeated as needed based on symptom recurrence 3

3. Lifestyle Modifications:

   • Antireflux diet limiting fat to no more than 45g in 24 hours
   • Elimination of trigger foods (coffee, tea, chocolate, citrus products, alcohol)
   • Weight loss for overweight patients
   • Avoiding meals 2-3 hours before lying down
   • Elevating the head of the bed for nocturnal symptoms

Second-Line Treatments

1. Botulinum Toxin Injection:

   • Well-studied treatment option with good symptomatic benefit 4
   • Particularly useful for diffuse esophageal spasm
   • Effect is temporary, requiring repeat injections

2. Advanced Endoscopic Techniques:

   • Consider EndoFLIP and Balloon pull-through techniques to optimize dilatation 3
   • Per-oral endoscopic myotomy (POEM) for refractory cases, especially for type III achalasia or spastic disorders 3, 5

3. Surgical Options:

   • Heller myotomy with fundoplication for severe, refractory cases 5
   • POEM should be considered the preferred treatment for type III achalasia with spastic features 3

Specific Approaches Based on Spasm Type

For Diffuse Esophageal Spasm:

• Initial trial of calcium channel blockers (diltiazem) 1, 2
• Consider botulinum toxin injection if pharmacotherapy fails 4
• POEM for refractory cases 5

For Distal Esophageal Spasm:

• Pharmacotherapy with calcium channel blockers or nitrates
• Botulinum toxin injection in the distal esophagus 5
• Consider POEM for carefully selected patients with confirmed pathologic findings 3

For Spasm with GERD:

• Add PPI therapy to treatment regimen
• Consider antireflux procedures if reflux is a significant component
• Dietary modifications to reduce reflux triggers 6

Important Considerations

• Symptom response after dilatation typically lasts up to 1 year 3
• Chest pain after dilatation is common but usually self-limiting 3
• Perforation rates for dilatation are similar to those for other esophageal diseases 3
• For non-achalasia spastic disorders, comprehensive evaluation with correlation of symptoms is essential before invasive treatments 3
• Medical therapy alone often provides limited clinical benefit, particularly for severe cases 2

Treatment Pitfalls to Avoid

• Treating based on symptoms alone without proper manometric diagnosis
• Overuse of PPIs without documented GERD
• Failing to address both motility and potential reflux components
• Delaying endoscopic or surgical interventions in severe, refractory cases
• Performing invasive procedures without confirming diagnosis with manometry

By following this structured approach to treatment, most patients with esophageal spasms can achieve significant symptom relief and improved quality of life.