What is the treatment for esophageal spasms?

Treatment of Esophageal Spasms

The treatment of esophageal spasms should begin with pharmacological therapy using calcium channel blockers, nitrates, or phosphodiesterase inhibitors, followed by endoscopic interventions such as botulinum toxin injection or dilatation for refractory cases. 1, 2

Initial Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Confirm diagnosis with esophageal manometry, which is the gold standard test for esophageal motility disorders 1
• Consider pH or impedance-pH monitoring to rule out GERD as a contributing factor 1
• Upper endoscopy to exclude structural abnormalities 1

Treatment Algorithm

First-Line Treatments

1. Pharmacological therapy:

   • Calcium channel blockers (e.g., diltiazem 60mg three times daily) 3, 2
   • Nitrates (short and long-acting) 2
   • 5-phosphodiesterase inhibitors 2
   • Proton pump inhibitors if GERD is present or suspected 1

2. Lifestyle modifications:

   • Weight loss if overweight/obese
   • Avoiding eating 2-3 hours before lying down
   • Elevating the head of bed 6-8 inches
   • Smoking cessation 1

Second-Line Treatments (for refractory symptoms)

1. Endoscopic interventions:

   • Botulinum toxin injection into the distal esophagus - currently the best-studied treatment option for diffuse esophageal spasm 4, 2
   • Esophageal dilatation - effective for patients with established tight strictures or narrow caliber esophagus 5

2. Adjunctive medications:

   • Visceral analgesics (tricyclic antidepressants or SSRIs) for pain management 1, 2
   • Anticholinergic agents 2

Third-Line Treatments (for severe refractory cases)

1. Surgical interventions:
   • Heller myotomy combined with fundoplication 2
   • Per oral endoscopic myotomy (POEM) - emerging technique showing promise 2

Special Considerations for Esophageal Dilatation

If dilatation is required:

• Use either balloon or wire-guided bougie dilators 5
• Consider limiting initial dilatation to 10-12 mm in diameter for very narrow strictures 5
• Use no more than three successively larger diameter increments in a single session 5
• Perform weekly or two-weekly dilatation sessions until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 5
• Monitor patients for at least 2 hours in recovery 5
• Inform patients that chest pain after dilatation is common 5

Treatment Efficacy and Monitoring

• Individual response to treatments varies significantly
• While diltiazem did not show significant overall improvement in one study, it provided relief in selected individual patients 3
• Botulinum toxin injection provides good symptomatic benefit in many patients, though many questions remain unanswered 4
• Symptom response after dilatation usually lasts up to 1 year 5
• Repeat treatments may be necessary as symptoms recur

Cautions and Pitfalls

• Muscle relaxants alone may not be effective for esophageal foreign body impaction, contrary to previous theories 6
• Given the intermittent nature of esophageal spasm, it can be difficult to definitively rule out the condition 7
• Esophageal spasm can sometimes progress to achalasia in some patients 2
• Botulinum toxin injection may potentially lead to gastroesophageal reflux as a side effect 2

By following this treatment algorithm and considering the individual patient's response to therapy, most patients with esophageal spasms can achieve significant symptom relief.