Management of Esophageal Spasm in a 34-Year-Old Female
Start with calcium channel blockers (diltiazem 30-60 mg before meals) or long-acting nitrates (isosorbide dinitrate 5-10 mg before meals) as first-line pharmacotherapy, and if symptoms persist after 4-6 weeks, proceed to endoscopic botulinum toxin injection into the distal esophageal body. 1, 2, 3
Initial Diagnostic Workup
Perform high-resolution esophageal manometry to confirm the diagnosis of distal esophageal spasm, defined by premature contractions with distal latency <4.5 seconds in the context of normal lower esophageal sphincter relaxation. 1, 4
Obtain upper endoscopy with biopsies (minimum 5 samples) to exclude alternative diagnoses including eosinophilic esophagitis, GERD-related complications, or structural abnormalities, particularly given the history of passing a clot which raises concern for mucosal injury. 1
Rule out cardiac causes of chest pain before attributing symptoms to esophageal spasm, as this is a critical pitfall—coronary artery disease must be excluded in any patient presenting with chest pain. 1
Pharmacological Management Algorithm
First-Line Therapy (4-6 week trial)
Calcium channel blockers (diltiazem 30-60 mg or nifedipine 10-20 mg before meals) reduce esophageal contractile force and show manometric improvement, though clinical benefit varies. 3, 4
Nitrates (short-acting sublingual nitroglycerin for acute episodes; long-acting isosorbide dinitrate 5-10 mg before meals for maintenance) work through nitric oxide-mediated smooth muscle relaxation. 3, 4
Proton pump inhibitors twice daily should be initiated empirically, as GERD frequently coexists with esophageal spasm and may contribute to symptom pathogenesis. 1, 4
Second-Line Therapy
Tricyclic antidepressants (such as imipramine 25-50 mg at bedtime, titrated up to 100 mg) or SSRIs serve as visceral analgesics and address the psychological component often present in esophageal motility disorders. 3, 4, 5
Psychological evaluation is warranted as 56% of esophageal spasm patients have major psychiatric disorders (anxiety, depression), and antidepressants showed 89% improvement rates in one prospective study. 5
Third-Line Therapy
Endoscopic botulinum toxin injection (100 IU diluted in 10 mL saline, injected at multiple sites along the distal esophageal wall in 1-1.5 cm intervals starting from the lower esophageal sphincter) provides 78-89% immediate symptom improvement with effects lasting 6-24 months. 2, 6
Repeat botulinum toxin injections are effective for symptom relapse, with similarly good results upon retreatment. 6
Surgical Considerations
Reserve Heller myotomy with fundoplication for the rare patient with severe, refractory symptoms unresponsive to all medical and endoscopic therapies. 4
Per-oral endoscopic myotomy (POEM) represents an emerging alternative endoscopic technique, though long-term data are limited. 4
Critical Clinical Pitfalls
Do not dismiss the "passing clot" history—this warrants endoscopic evaluation to exclude mucosal injury, esophageal perforation, or bleeding lesions that could masquerade as or coexist with esophageal spasm. 1
Avoid attributing all chest pain to esophageal spasm without cardiac workup, as this represents a dangerous missed diagnosis. 1
Recognize that medical therapy alone is often disappointing—only a subset of patients achieve meaningful clinical improvement despite manometric improvements, necessitating progression through the treatment algorithm. 3
Monitor for progression to achalasia, as small case series suggest esophageal spasm can evolve into achalasia over time. 4
Follow-Up Strategy
Reassess symptoms at 4-6 weeks after initiating pharmacotherapy to determine response and need for escalation. 3, 4
Consider repeat manometry if symptoms persist despite treatment to evaluate for disease progression or alternative diagnoses. 1
Screen for psychological comorbidities including anxiety and depression, as these substantially impact symptom perception and treatment response. 5