What is the initial management for esophageal spasms?

Initial Management of Esophageal Spasms

The initial management for esophageal spasms should focus on smooth muscle relaxants, neuromodulators, and proton pump inhibitors (PPIs), with endoscopic interventions reserved for refractory cases. 1

Pharmacological First-Line Therapy

• Proton pump inhibitors (PPIs) are recommended as initial therapy for esophageal spasms, especially when symptoms overlap with gastroesophageal reflux disease (GERD) 2
• Smooth muscle relaxants are effective first-line medications for symptom management in esophageal spasms 1
• Calcium channel blockers like diltiazem (60mg three times daily) may provide relief in selected individual patients, though clinical trials show variable response 3
• Nitrates (nitroglycerine and long-acting nitrites) can be effective, particularly in patients without associated gastroesophageal reflux 4
• GABA-B agonists such as baclofen may be beneficial for regurgitation and belch-predominant symptoms, though they can cause CNS and GI side effects 1

Diagnostic Considerations Before Treatment

• High-resolution manometry is essential for accurate diagnosis and classification of esophageal motility disorders before initiating treatment 1
• Upper GI endoscopy should be performed to rule out structural abnormalities and to obtain biopsies if eosinophilic esophagitis is suspected 2
• Ambulatory impedance-pH monitoring may be used to rule out GERD as a contributing factor 1

Endoscopic Interventions for Refractory Cases

• Endoscopic injection of botulinum toxin is currently the best-studied treatment option for patients with diffuse esophageal spasm who fail to respond to pharmacological therapy 5
• Botulinum toxin (100 IU diluted in 10mL saline) can be injected at multiple sites along the esophageal wall, starting at the lower esophageal sphincter and moving proximally at 1-1.5cm intervals 6
• Symptom improvement occurs in approximately 78-89% of patients after botulinum toxin injection, with effects lasting 6-24 months 6
• Esophageal dilation is recommended for patients with associated strictures or narrowing, using balloon dilation or bougie dilators guided by wire 1, 7

Behavioral Interventions

• Cognitive behavioral therapy, esophageal-directed hypnotherapy, and diaphragmatic breathing techniques can be effective for esophageal disorders with associated hypervigilance or hypersensitivity 1

Surgical Options

• Per-oral endoscopic myotomy (POEM) is recommended for type III achalasia and may be beneficial in select cases of distal esophageal spasm that are refractory to other treatments 1
• Surgical myotomy should be considered only for patients with very severe symptoms refractory to pharmacologic and endoscopic treatments 5

Treatment Algorithm

1. Start with PPI therapy and smooth muscle relaxants (calcium channel blockers or nitrates) 2, 1
2. If symptoms persist after 4-8 weeks, consider adding neuromodulators or switching to a different smooth muscle relaxant 1
3. For persistent symptoms despite medication optimization, proceed to endoscopic botulinum toxin injection 5, 6
4. For patients with associated strictures, consider endoscopic dilation 1, 7
5. Reserve surgical interventions for truly refractory cases 1, 5

Common Pitfalls and Caveats

• Metoclopramide is not recommended as monotherapy or adjunctive therapy in patients with esophageal syndromes due to fair evidence that it is ineffective or harms outweigh benefits 2
• Failure to identify and treat concurrent GERD may lead to persistent symptoms despite appropriate therapy for esophageal spasm 4
• Botulinum toxin effects are temporary, and patients may require repeated injections every 6-24 months 6
• Always rule out eosinophilic esophagitis, which can present with similar symptoms and requires different management approaches 2