What are the treatment options for esophageal spasms?

Treatment of Esophageal Spasms

For distal esophageal spasm (DES), initiate treatment with smooth muscle relaxants (nitrates or calcium channel blockers) combined with proton pump inhibitors, reserving endoscopic botulinum toxin injection for refractory cases and per-oral endoscopic myotomy (POEM) for severe, treatment-resistant patients. 1

Initial Pharmacological Management

First-Line Therapy

• Start with proton pump inhibitors (PPIs) as initial therapy, particularly when symptoms overlap with gastroesophageal reflux disease (GERD), which frequently coexists in esophageal spasm 1, 2
• Add smooth muscle relaxants as primary pharmacological agents 1:
  • Nitrates: Both short-acting (sublingual nitroglycerin) and long-acting nitrates are effective, particularly in patients without concurrent reflux 3
  • Calcium channel blockers: Can reduce esophageal contractile force and provide symptomatic relief 2, 4
  • In patients with diffuse esophageal spasm without gastroesophageal reflux, nitrates show uniformly good response with long-term symptom control (6 months to 4 years) 3

Neuromodulators

• Consider tricyclic antidepressants or SSRIs as visceral analgesics for chest pain predominant symptoms 2
• Baclofen (GABA-B agonist) may be effective for regurgitation and belch-predominant symptoms, though CNS and GI side effects should be monitored 1

Important Caveat

• Avoid metoclopramide as monotherapy or adjunctive therapy, as evidence shows it is ineffective or causes more harm than benefit 1
• If esophageal spasm is associated with reflux esophagitis, nitrates are less effective than in isolated spasm; use nitrites as an adjunct to antireflux therapy rather than primary treatment 3

Diagnostic Workup Before Treatment

Essential Investigations

• Perform high-resolution manometry (HRM) for accurate diagnosis and classification before initiating treatment 1
  • The Chicago Classification defines DES as at least two premature contractions (distal latency <4.5 seconds) with normal esophagogastric junction relaxation 2
• Conduct upper GI endoscopy to rule out structural abnormalities and obtain biopsies if eosinophilic esophagitis is suspected 1
• Consider ambulatory impedance-pH monitoring to rule out GERD and assess for concurrent reflux disease 1

Endoscopic Interventions

Botulinum Toxin Injection

• Offer endoscopic botulinum toxin injection for patients who fail pharmacological therapy 1, 5
• Inject 100 IU botulinum toxin diluted in 10 mL saline at multiple sites along the esophageal wall, beginning at the lower esophageal sphincter and moving proximally in 1- to 1.5-cm intervals 6
• Expect immediate improvement in 78% of patients, with 89% in remission at 4 weeks 6
• Symptom relief typically lasts 8-24 months, and reinjection is effective for recurrent symptoms 6
• This is currently the best-studied treatment option for diffuse esophageal spasm 5

Esophageal Dilation

• Use balloon dilation or bougie dilators for patients with associated strictures or narrowing 1
• Dilation may provide benefit in select cases, though evidence is limited for isolated spasm without stricture 2

Surgical and Advanced Endoscopic Options

Per-Oral Endoscopic Myotomy (POEM)

• Consider POEM as the preferred treatment for type III achalasia (achalasia with spasm) and may be beneficial in select cases of refractory distal esophageal spasm 7, 1
• POEM should be performed by experienced physicians in high-volume centers, as 20-40 procedures are needed to achieve competence 7
• Warn patients about high risk of post-POEM reflux esophagitis requiring potential indefinite PPI therapy and/or surveillance endoscopy 7

Heller Myotomy

• Reserve Heller myotomy combined with fundoplication for rare patients with very severe symptoms refractory to all other treatments 2, 4

Behavioral and Adjunctive Interventions

• Consider cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing for patients with associated hypervigilance or hypersensitivity 1
• Benzodiazepines or antidepressants may provide clinical benefit given the psychological component in symptom perception 4

Treatment Algorithm Summary

1. Rule out structural disease and GERD with endoscopy and pH monitoring 1
2. Start PPI therapy for all patients, especially with GERD overlap 1
3. Add smooth muscle relaxants (nitrates or calcium channel blockers) 1, 2
4. If refractory after 4-8 weeks, proceed to botulinum toxin injection 6
5. For persistent severe symptoms, consider POEM in experienced centers 7, 1
6. Reserve surgical myotomy for exceptional cases failing all other therapies 2

Critical Pitfalls to Avoid

• Failure to identify and treat concurrent GERD leads to persistent symptoms despite appropriate spasm therapy 1
• Missing eosinophilic esophagitis, which presents with similar symptoms but requires different management (topical steroids, dietary modification) 1
• Using nitrates in patients with significant reflux without adequate acid suppression reduces efficacy 3
• Attempting POEM without adequate expertise or in low-volume centers increases complication risk 7