What is the initial treatment for esophageal spasm?

Initial Treatment for Esophageal Spasm

The initial treatment for esophageal spasm should be a combination of proton pump inhibitors (PPIs) and smooth muscle relaxants such as calcium channel blockers or nitrates. 1

First-Line Pharmacological Therapy

Medication Options

• Primary medications:

  • Proton pump inhibitors (PPIs) - to reduce acid reflux that may trigger or worsen spasms
  • Smooth muscle relaxants:
    • Calcium channel blockers (e.g., nifedipine, diltiazem)
    • Nitrates (short-acting for acute symptoms, long-acting for maintenance)

• For patients without GERD:

  • Long-acting nitrates are preferred for maintenance therapy 1

• For treatment-resistant cases:

  • Phosphodiesterase-5 inhibitors (e.g., sildenafil) may be used to reduce peristaltic pressure and velocity 1
  • Visceral analgesics (tricyclic antidepressants or SSRIs) can help manage pain 1, 2

Assessment and Follow-up

• Evaluate symptom response after 4-8 weeks of pharmacologic therapy 1
• If symptoms persist despite medication optimization, consider endoscopic evaluation

Second-Line Interventions

If pharmacological therapy fails to provide adequate relief:

Endoscopic Treatments

• Botulinum toxin injection:

  • Indicated when pharmacologic therapy fails
  • Efficacy: 78-89% of patients show immediate improvement after one session
  • Technique: 100 IU diluted in 10mL saline solution injected at multiple sites along the esophageal wall 1, 3
  • Follow-up at 1 month and 6 months after treatment 1

• Endoscopic dilatation:

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

Advanced Interventions for Refractory Cases

For severe, refractory cases that don't respond to pharmacological and endoscopic treatments:

• Per-Oral Endoscopic Myotomy (POEM):

  • Recommended for severe, refractory cases, especially Type III achalasia with spastic features
  • Allows unlimited proximal extension of myotomy to address spastic segments 1
  • Follow-up at 1,3, and 12 months after procedure 1

• Surgical myotomy:

  • Reserved for extremely refractory cases
  • Often combined with fundoplication 4

Important Considerations

• Assess for and treat coexisting GERD, which frequently occurs with esophageal spasm 1
• Distinguish between different types of esophageal motility disorders before initiating treatment
• Consider medication side effects as potential causes of esophageal dysmotility
• Avoid proceeding to invasive treatments without adequate trials of conservative management

By following this treatment algorithm, clinicians can provide effective management for patients with esophageal spasm while minimizing unnecessary invasive procedures and optimizing outcomes related to morbidity, mortality, and quality of life.