What are esophageal spasms and how are they managed?

Esophageal Spasms: Clinical Description and Management

What Are Esophageal Spasms?

Esophageal spasms are uncommon esophageal motility disorders characterized by abnormal, simultaneous contractions of the distal (smooth muscle) esophagus that present clinically with squeezing retrosternal chest pain and/or dysphagia. 1

Clinical Presentation

• Chest pain is the predominant symptom, often described as squeezing or spasm-like, which can mimic cardiac ischemia and requires careful cardiac evaluation before accepting an esophageal diagnosis 1
• Dysphagia frequently accompanies the chest pain, distinguishing it from purely cardiac causes 1, 2
• Symptoms are intermittent in nature, making diagnosis challenging as the disorder may not be present during testing 3, 4
• Pain duration ranges from minutes to hours and may worsen with stress or occur after meals 1

Diagnostic Criteria

• High-resolution manometry (HRM) is essential for accurate diagnosis, with modern criteria requiring at least two premature contractions (distal latency <4.5 seconds) in the context of normal lower esophageal sphincter relaxation 5, 2
• Traditional criteria defined distal esophageal spasm as ≥20% simultaneous esophageal contractions during standardized motility testing 3, 2
• Barium swallow may show the classic "corkscrew esophagus" pattern, though this has low sensitivity and specificity 3, 6

Management Algorithm

Step 1: Rule Out Cardiac and GERD Etiologies

Cardiac evaluation must be completed first given the substantially greater morbidity and mortality of ischemic heart disease compared to esophageal disorders 1

• Once cardiac causes are excluded, gastroesophageal reflux disease (GERD) should be investigated or treated empirically, as simultaneous contractions may result from reflux 3, 2
• Proton pump inhibitors (PPIs) are recommended as initial therapy, especially when symptoms overlap with GERD 7
• If symptoms persist despite PPI therapy, proceed with diagnostic evaluation including upper endoscopy to rule out structural abnormalities and eosinophilic esophagitis 7, 5

Step 2: Pharmacological Management

The American Gastroenterological Association recommends smooth muscle relaxants, neuromodulators, and acid suppression as first-line pharmacological approaches. 7

• Smooth muscle relaxants including nitrates (short and long-acting) and calcium-channel blockers have documented improvements in small studies 3, 2
• Neuromodulators such as tricyclic antidepressants or SSRIs are effective for esophageal hypersensitivity and visceral analgesia 7, 3, 2
• Baclofen (GABA-B agonist) may be effective for regurgitation and belch-predominant symptoms, though CNS and GI side effects can occur 7

Important caveat: Metoclopramide should NOT be used as it is ineffective and potential harms outweigh benefits 7

Step 3: Endoscopic Interventions for Non-Responders

Endoscopic botulinum toxin injection is the best-studied minimally invasive treatment option for patients who fail pharmacological therapy 7, 8

• Botulinum toxin injection into the distal esophagus results in good symptomatic benefit in multiple case series 8, 2
• Esophageal dilation using balloon dilation or bougie dilators is recommended for patients with associated strictures or narrowing 7, 6
• Pneumatic dilation has shown success in high-risk patients not suitable for surgery 6

Step 4: Surgical Options for Refractory Cases

Per-oral endoscopic myotomy (POEM) is the preferred surgical approach for refractory distal esophageal spasm, with success rates >90% 7, 5

• POEM provides the advantage of unlimited proximal extension of myotomy compared to laparoscopic approaches 5
• Traditional Heller myotomy combined with fundoplication remains an alternative for rare refractory patients 2
• Surgical myotomy should be reserved for patients with very severe symptoms refractory to all other treatments 3, 8

Step 5: Adjunctive Behavioral Therapies

Cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing can be effective for patients with associated hypervigilance or hypersensitivity 7, 5

Critical Diagnostic Considerations

• Complete evaluation should include esophagogram, endoscopy, manometry, and pH monitoring to establish comprehensive diagnosis 5
• Ambulatory impedance-pH monitoring may be used to definitively rule out GERD if diagnosis remains unclear 7
• Check electrolyte abnormalities (particularly magnesium and potassium) which can affect esophageal motility 5
• Adjunctive testing during HRM with larger volumes of water or solid/viscous swallows can unmask pathology not seen with standard water swallows 5

Common Pitfalls to Avoid

• Failure to adequately exclude cardiac ischemia before pursuing esophageal diagnosis can result in catastrophic outcomes 1
• Not identifying and treating concurrent GERD may lead to persistent symptoms despite appropriate spasm-directed therapy 7, 3
• Missing eosinophilic esophagitis, which presents with similar symptoms but requires different management (biopsy during endoscopy is essential) 7
• Recognizing that symptoms may not correlate with physiological improvement after treatment, requiring both symptom assessment and objective testing during follow-up 5