How are esophageal spasm symptoms managed?

Management of Esophageal Spasm Symptoms

Esophageal spasm symptoms should be managed with a personalized approach starting with lifestyle modifications and PPI therapy, followed by adjunctive pharmacotherapy tailored to symptom phenotype, and progressing to neuromodulators or invasive procedures for refractory cases. 1

First-Line Therapy

• Lifestyle optimization and weight management should be implemented as initial management for patients with esophageal spasm symptoms 1
• Proton pump inhibitors (PPIs) are the first-line pharmacologic treatment, as they are more effective than histamine-2 receptor antagonists (H2RAs), which are more effective than placebo 1
• PPI optimization includes ensuring adequate timing of dose, considering escalation to twice daily dosing, or switching to a different PPI if symptoms persist 1
• When symptoms are adequately controlled, acid suppression should be weaned to the lowest effective dose or switched to H2RAs or other antacids 1

Adjunctive Pharmacotherapy

• Adjunctive therapy should be tailored to the specific symptom phenotype rather than used empirically 1
• Alginate antacids are useful for breakthrough symptoms, particularly post-prandial and nighttime symptoms, and in patients with hiatal hernia 1
• H2RAs may help with breakthrough and nighttime symptoms, though their effectiveness is limited by tachyphylaxis 1
• Baclofen (a GABA-B agonist) may be effective for belch-predominant symptoms and mild regurgitation, though often limited by CNS and GI side effects 1
• Smooth muscle relaxants such as calcium channel blockers and nitrates have been used for esophageal spasm, though clinical results are often modest 2

Advanced Therapies for Refractory Symptoms

• For patients with persistent symptoms despite lifestyle and PPI optimization, neuromodulation with low-dose antidepressants should be considered 1
• Behavioral interventions including cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing are beneficial for patients with esophageal hypervigilance, hypersensitivity, or behavioral disorders 1
• Botulinum toxin injection into the esophageal wall is an effective treatment option for diffuse esophageal spasm, with studies showing good symptomatic relief 3, 4
• Endoscopic injection of botulinum toxin at multiple sites along the esophageal wall can provide symptom relief for up to 6 months, with the possibility of reinjection for recurrent symptoms 4

Diagnostic Evaluation for Refractory Cases

• If symptoms remain inadequately controlled despite optimization of therapy, additional testing should be performed 1
• High-resolution manometry should be used to assess esophageal peristaltic function and exclude achalasia 1
• Gastric emptying testing may be indicated if delayed gastric emptying is suspected 1
• Ambulatory 24-hour pH-impedance monitoring on PPI therapy can help determine the mechanism of persisting symptoms and exclude other etiologies 1

Surgical and Endoscopic Options

• For severely refractory cases, surgical interventions such as laparoscopic fundoplication may be considered 1
• Type of fundoplication can be tailored, with partial fundoplication preferred in patients with esophageal hypomotility 1
• Per oral endoscopic myotomy (POEM) is an emerging endoscopic technique that may be an alternative treatment modality for selected patients 5

Common Pitfalls and Caveats

• Metoclopramide is not recommended as monotherapy or adjunctive therapy for esophageal GERD syndromes 1
• Prokinetics have not been shown to be useful in GERD but may have a role in patients with concomitant gastroparesis 1
• Esophageal hypervigilance and visceral hypersensitivity can augment symptom burden and should be addressed with appropriate neuromodulation or behavioral interventions 1
• Sleeve gastrectomy has potential to worsen GERD symptoms and should be avoided in patients with proven GERD 1