What is the treatment for a spasm below the ribs?

Treatment for Spasm Below the Ribs

The first-line treatment for spasm below the ribs is calcium channel blockers (such as verapamil 2.5-5 mg, diltiazem 2.5-5 mg) or nitroglycerin (100-200 μg), which should be administered to effectively reduce spasm. 1

Pharmacological Management

First-line Treatments

• Calcium channel blockers are highly effective for treating muscle spasm below the ribs and should be considered first-line therapy 1
• Nitroglycerin (100-200 μg) can be used alone or in combination with calcium channel blockers to provide rapid relief of spasm 1
• Dicyclomine (Bentyl) is effective for gastrointestinal smooth muscle spasm through both anticholinergic and direct smooth muscle relaxant effects 2, 1
• Hyoscine butylbromide (Buscopan) is an effective antimuscarinic that may be more effective when administered intramuscularly for persistent spasm 1

Second-line Treatments

• Alpha-receptor blockers can be beneficial, especially in patients who do not respond completely to calcium channel blockers and nitrates 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) can be used as adjunctive therapy for pain control and anti-inflammatory effects 3
• Low-dose ketamine (0.3 mg/kg over 15 minutes) can be considered as an alternative to opioids for severe pain 3

Non-pharmacological Approaches

Heat and Cold Therapy

• Application of local heat can effectively reduce muscle spasm by decreasing muscle tone and increasing blood flow to the affected area 4
• Cold therapy can also be effective for acute spasm and may be more beneficial in certain cases, particularly when inflammation is present 4
• Alternating heat and cold applications may provide enhanced relief for persistent spasm 4

Physical Interventions

• Immobilization of the affected area can help reduce pain and prevent exacerbation of spasm 3
• For persistent cases related to rib pathology, intercostal nerve blocks may provide immediate relief, though evidence for long-term efficacy is limited 5

Specific Management Based on Underlying Cause

Coronary Vasospasm (Prinzmetal's Angina)

If spasm below the ribs is due to coronary vasospasm:

• Long-acting nitrates and calcium channel blockers are the definitive first-line treatment 1
• Discontinuation of smoking is essential as it can trigger and worsen vasospasm 1
• For very active disease, a combination of nitrates and two different classes of calcium channel blockers may be necessary 1

Gastrointestinal Spasm

If the spasm is related to gastrointestinal issues:

• Dicyclomine hydrochloride (10-20 mg orally) is highly effective due to its dual mechanism of action 2, 1
• Reducing fiber in the diet can decrease abdominal distension and associated spasm 1
• Peppermint oil may help relieve gastrointestinal spasm through its antispasmodic properties 1

Rib-Related Spasm

If the spasm is related to rib fractures or rib syndrome:

• Regular administration of acetaminophen every 6 hours is recommended as first-line treatment 3
• For twelfth rib syndrome, conservative treatment including local heat or ice packs, rest, and oral analgesics should be tried first 5
• In severe cases with unstable chest wall, surgical fixation may be considered 1, 3

Monitoring and Follow-up

• Pain from rib-related spasm typically improves significantly within 4 weeks with appropriate management 3
• Complete healing of rib fractures usually occurs within 6-8 weeks, but full recovery may take longer 3
• Persistent spasm beyond expected recovery time may indicate an underlying condition requiring further evaluation 6

Cautions

• Use caution with spasmolytics in patients with cardiogenic shock, severely reduced ejection fraction, or severe aortic stenosis 1
• Beta-blockers have theoretical adverse potential in coronary spasm and their clinical effect is controversial 1
• For painful rib syndrome, unnecessary investigations and treatments should be avoided as it is a clinical diagnosis 6