What are the treatment options for esophageal spasms?

Treatment Options for Esophageal Spasms

The most effective treatment approach for esophageal spasms includes smooth muscle relaxants, neuromodulators, and endoscopic botulinum toxin injections, with surgical interventions reserved for refractory cases. 1

Diagnostic Considerations Before Treatment

• High-resolution manometry (HRM) 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 1
• Ambulatory impedance-pH monitoring may be used to rule out GERD as a contributing factor 1

Pharmacological Management

• Proton pump inhibitors (PPIs) are recommended as initial therapy, especially when symptoms overlap with gastroesophageal reflux disease (GERD) 1
• Smooth muscle relaxants such as nitrates and calcium channel blockers can reduce esophageal contractile force and may provide symptomatic relief 1, 2
• Baclofen, a GABA-B agonist, may be effective for regurgitation and belch-predominant symptoms, though it can cause CNS and GI side effects 1
• Antidepressants (particularly serotonin reuptake inhibitors) have shown effectiveness in treating esophageal spasms, especially in patients with concurrent anxiety or depression 3
• Metoclopramide is not recommended as monotherapy or adjunctive therapy due to fair evidence that it is ineffective or harms outweigh benefits 1

Endoscopic Interventions

• Botulinum toxin injection is currently the best-studied treatment option for esophageal spasms 4
  • Typically administered at multiple sites along the esophageal wall beginning at the lower esophageal sphincter and moving proximally 5
  • Studies show immediate improvement in 78% of patients after one injection session, with sustained benefits at 6 months 5
  • Symptom relapse can be effectively treated with repeated injections 5
• Esophageal dilation is recommended for patients with associated strictures or narrowing, using balloon dilation or bougie dilators guided by wire 1

Surgical Options for Refractory Cases

• Per-oral endoscopic myotomy (POEM) is the preferred treatment for type III achalasia and may be beneficial in select cases of distal esophageal spasm 1
• Heller myotomy combined with fundoplication remains an alternative for rare refractory patients 6

Behavioral Interventions

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

Treatment Algorithm

1. First-line therapy: Start with PPIs, especially if GERD symptoms are present 1
2. Second-line therapy: Add smooth muscle relaxants (calcium channel blockers or nitrates) 1, 2
3. Third-line therapy: Consider botulinum toxin injections if symptoms persist 4, 5
4. Fourth-line therapy: For refractory cases, consider POEM or surgical myotomy 1, 6
5. Adjunctive therapy: Add antidepressants if psychological factors are present or other treatments provide insufficient relief 3

Common Pitfalls and Caveats

• Failure to identify and treat concurrent GERD may lead to persistent symptoms despite appropriate therapy 1
• It is essential to rule out eosinophilic esophagitis, which can present with similar symptoms but requires different management 1
• Despite beneficial effects on esophageal motility parameters, the clinical benefit of medical treatment can be disappointing in some patients 2
• Botulinum toxin may cause post-injection gastroesophageal reflux in some patients 6