Initial Management of Esophageal Spasm
Start with proton pump inhibitors (PPIs) as first-line therapy, particularly when symptoms overlap with GERD, followed by smooth muscle relaxants or neuromodulators if symptoms persist. 1
Immediate Diagnostic Steps
Before initiating treatment, perform upper GI endoscopy to exclude structural abnormalities, malignancy, and eosinophilic esophagitis, which can mimic esophageal spasm but requires entirely different management. 1 High-resolution manometry (HRM) is essential for accurate diagnosis and classification of the motility disorder before committing to specific therapies. 1
First-Line Pharmacological Approach
PPIs as Initial Therapy
- Begin with PPIs regardless of whether reflux symptoms are prominent, as GERD frequently coexists with esophageal spasm and untreated reflux will undermine all other therapeutic efforts. 1, 2, 3
- This is particularly critical since esophageal spasm associated with reflux responds poorly to smooth muscle relaxants alone. 3
Smooth Muscle Relaxants (Second Step)
If symptoms persist after adequate PPI trial:
- Nitrates (sublingual nitroglycerin or long-acting nitrites) are highly effective for diffuse esophageal spasm without reflux, with sustained symptom control documented for 6 months to 4 years. 3
- Calcium channel blockers like diltiazem (60 mg three times daily) may provide relief in selected individual patients, though overall efficacy is inconsistent. 4
- The American Gastroenterological Association endorses smooth muscle relaxants as effective treatment approaches. 1
Neuromodulators (Third Step)
- Antidepressants can be beneficial for esophageal spasm, particularly when there is associated hypervigilance or hypersensitivity. 1, 2
- Baclofen may help with regurgitation and belch-predominant symptoms, though CNS and GI side effects limit tolerability. 1
Critical Pitfall to Avoid
Never use metoclopramide for esophageal spasm—the American Gastroenterological Association explicitly recommends against it due to evidence that harms outweigh benefits. 1
Endoscopic Intervention for Persistent Symptoms
Botulinum toxin injection is the best-studied treatment option for refractory esophageal spasm, with 78-89% of patients achieving remission after a single injection session. 5, 6 The technique involves:
- Injecting 100 IU botulinum toxin diluted in 10 mL saline at multiple sites along the esophageal wall
- Starting at the lower esophageal sphincter and moving proximally in 1-1.5 cm intervals
- Targeting any visible contraction rings 6
- Symptom relief lasts 8-24 months, and reinjection is effective for recurrence. 6
Surgical Options for Refractory Cases
Per-oral endoscopic myotomy (POEM) is the preferred surgical treatment for type III achalasia and may benefit select cases of distal esophageal spasm refractory to all other therapies. 1 Traditional surgical myotomy should be reserved for patients with very severe symptoms who have failed pharmacologic and endoscopic treatments. 5
Adjunctive Behavioral Interventions
Cognitive behavioral therapy, esophageal-directed hypnotherapy, and diaphragmatic breathing can be effective when hypervigilance or hypersensitivity contributes to symptoms. 1