What is the recommended treatment for esophageal spasm symptoms?

Esophageal Spasm Symptoms and Treatment

For esophageal spasm, the recommended first-line treatment is proton pump inhibitors (PPIs), followed by smooth muscle relaxants such as calcium channel blockers or nitrates, with botulinum toxin injection being effective for refractory cases. 1

Symptoms of Esophageal Spasm

• Chest pain: Often severe, may mimic cardiac pain
• Dysphagia: Difficulty swallowing, particularly with solids
• Regurgitation: Food or liquid returning to the mouth
• Non-cardiac chest pain: Can be mistaken for heart-related issues
• Symptoms worsened by: Hot or cold liquids, stress, or certain foods

Diagnostic Approach

• High-resolution manometry (HRM): Gold standard for diagnosis of esophageal motility disorders 1
• Upper GI endoscopy: To rule out mechanical obstruction and evaluate esophageal mucosa
• Timed barium esophagram: To evaluate esophageal emptying and confirm outflow obstruction
• pH/impedance monitoring: To rule out reflux as a contributing factor 1

Treatment Algorithm

Step 1: First-Line Therapy

• Proton pump inhibitors (PPIs): Even without GERD, PPIs are recommended as first-line therapy as they can reduce acid reflux that may trigger or worsen spasms 1, 2
  • Standard dosing: Once daily dosing initially
  • If inadequate response: Consider twice-daily dosing 2

Step 2: Smooth Muscle Relaxants

• Calcium channel blockers:

  • Diltiazem (60mg three times daily) may provide relief in selected patients 3
  • Consider in patients with persistent symptoms despite PPI therapy

• Nitrates:

  • Long-acting nitrates can be effective, especially in patients without gastroesophageal reflux 4
  • Can provide long-term symptom relief (documented effectiveness for up to 4 years) 4

Step 3: Endoscopic Interventions

• Botulinum toxin injection:

  • Highly effective for refractory cases with 78-89% showing immediate improvement 1, 5
  • Technique: 100 IU diluted in 10mL saline injected at multiple sites along the esophageal wall 1, 5
  • Benefits can last 6-24 months; retreatment is effective when symptoms recur 5

• Pneumatic dilation:

  • Consider for persistent symptoms, particularly in achalasia-like presentations 2
  • Perform under endoscopic or fluoroscopic control 2

Step 4: Surgical Options

• Per-Oral Endoscopic Myotomy (POEM):
  • Consider for severe, refractory cases, especially Type III achalasia-like spasm 1
  • Success rates of 89-97% for symptom improvement 1

Lifestyle and Dietary Modifications

• Avoid foods that trigger symptoms (coffee, alcohol, chocolate, fatty foods) 2
• Avoid acidic foods that may precipitate symptoms (citrus, carbonated drinks, spicy foods) 2
• Small, frequent meals rather than large meals 1
• Elevate the head of the bed for nighttime symptoms 2
• Weight loss if overweight or obese 2

Follow-up and Monitoring

• Assess response to therapy after 4-8 weeks
• If symptoms persist despite PPI therapy, consider:
  • Increasing PPI dose to twice daily 2
  • Adding a smooth muscle relaxant 1
  • Endoscopic evaluation if not previously performed
• For patients receiving botulinum toxin, follow-up at 1 month and 6 months to assess treatment efficacy 1, 5

Important Considerations

• Reflux association: Patients with esophageal spasm and coexisting GERD may have less predictable response to smooth muscle relaxants alone; combined therapy with PPIs is recommended 4, 1

• Medication pitfalls: Avoid medications that worsen dysmotility, such as opioids, anticholinergics, and sedatives 1

• Symptom-histology mismatch: Symptoms may not always correlate with disease activity; objective testing is essential 2

• Low-dose antidepressants: Consider when pain is a predominant symptom to modulate visceral hypersensitivity 1

By following this treatment algorithm and considering the individual presentation of symptoms, most patients with esophageal spasm can achieve significant symptom relief and improved quality of life.