What is the treatment for esophageal spasm?

Treatment for Esophageal Spasm

The most effective treatment approach for esophageal spasm includes proton pump inhibitors as first-line therapy, followed by smooth muscle relaxants, and potentially botulinum toxin injections for refractory cases. 1

First-Line Medical Therapy

• Proton Pump Inhibitors (PPIs):

  • Recommended even without GERD, as they reduce acid reflux that may trigger or worsen spasms 1
  • Start with standard once-daily dosing
  • Consider twice-daily dosing if inadequate response after 4-8 weeks 1

• Smooth Muscle Relaxants:

  • Calcium channel blockers (e.g., nifedipine)
  • Nitrates (short and long-acting)
  • Should be prescribed concurrently with PPIs 1, 2

Second-Line Therapy

• Low-dose Antidepressants:

  • Particularly effective when pain is a predominant symptom 1
  • Tricyclic agents or SSRIs help modulate visceral hypersensitivity
  • Studies show significant improvement in patients with esophageal spasm using antidepressants 3

• 5-phosphodiesterase Inhibitors:

  • Sildenafil blocks nitric oxide degradation, prolonging esophageal muscle relaxation 4
  • Promising treatment option for refractory cases

Procedural Interventions for Refractory Cases

• Botulinum Toxin Injection:

  • Technique: 100 IU diluted in 10mL saline injected at multiple sites along the esophageal wall 1, 5
  • Efficacy: 78-89% of patients show immediate improvement 1
  • Studies show symptom improvement in up to 78% of patients after one injection session 5
  • Benefits can last 6-24 months; reinjection is effective for symptom relapse 5

• Endoscopic Dilatation:

  • Consider for patients with associated strictures or narrow-caliber esophagus 6
  • Weekly or two-weekly sessions until passage of ≥15 mm dilator is achieved 6

• Per-Oral Endoscopic Myotomy (POEM):

  • For severe, refractory cases, especially those resembling Type III achalasia 1
  • Success rates of 89-97% for symptom improvement 1

• Surgical Myotomy:

  • Reserved for extremely refractory cases after failure of other therapeutic options 2, 4

Lifestyle Modifications

• Avoid trigger foods: coffee, alcohol, chocolate, fatty foods, and acidic foods 1
• Consume small, frequent meals rather than large meals 1
• Elevate the head of the bed to alleviate nighttime symptoms 1
• Weight loss if overweight or obese 1
• Avoid medications that worsen dysmotility (opioids, anticholinergics, sedatives) 1

Follow-up and Monitoring

• Assess response to therapy after 4-8 weeks 1
• If symptoms persist despite PPI therapy:
  • Increase PPI dose to twice daily
  • Add a smooth muscle relaxant 1
• Schedule follow-up at 1 month and 6 months to assess treatment efficacy 1

Pitfalls and Caveats

1. Diagnostic Accuracy: Ensure proper diagnosis with high-resolution manometry before initiating treatment 1
2. GERD Coexistence: GERD frequently coexists with esophageal spasm and requires appropriate management 2
3. Disease Progression: Some evidence suggests that distal esophageal spasm can progress to achalasia, requiring vigilant follow-up 2
4. Post-POEM Reflux: Common complication requiring ongoing PPI therapy 1
5. Botulinum Toxin Side Effects: Consider potential development of post-injection gastroesophageal reflux 2

By following this treatment algorithm and being aware of potential complications, most patients with esophageal spasm can achieve significant symptom relief and improved quality of life.