Initial Treatment of Esophageal Spasms
Begin with proton pump inhibitors (PPIs) as first-line pharmacological therapy, especially when symptoms overlap with gastroesophageal reflux disease (GERD), which frequently coexists with esophageal spasms. 1, 2
Immediate Diagnostic Workup Required
Before initiating treatment, you must establish the correct diagnosis and exclude structural pathology:
- Perform upper endoscopy with biopsies at two levels to rule out eosinophilic esophagitis, structural lesions, and mucosal disease that can mimic dysmotility 2
- Obtain high-resolution manometry (HRM) as the definitive test to characterize the specific motility disorder pattern and guide treatment decisions 1, 2
- Consider biphasic barium esophagram if endoscopy is unrevealing, as it has 80-89% sensitivity for detecting esophageal motility disorders 2
- Review all current medications to rule out drug-induced dysmotility, particularly opioids, cyclizine, and anticholinergics 2
First-Line Pharmacological Management
Start with PPIs as initial therapy since GERD frequently coexists with esophageal spasms and contributes to symptomatology 1, 2, 3
After initiating PPIs, add smooth muscle relaxants if symptoms persist:
- Calcium channel blockers (such as diltiazem) or nitrates can be used for spastic disorders, though clinical benefit is often limited despite manometric improvement 2, 4, 5
- Individual patients may respond favorably to calcium channel antagonists even when group studies show modest overall benefit 4, 6
Add neuromodulators (tricyclic antidepressants or SSRIs) for patients with chest pain or hypersensitivity components 1, 2, 5
Consider baclofen (GABA-B agonist) specifically for regurgitation and belch-predominant symptoms, but monitor for CNS and GI side effects 1, 2
Second-Line Endoscopic Interventions
If pharmacological therapy fails after adequate trial (typically 4-8 weeks):
Endoscopic botulinum toxin injection into the distal esophagus is the best-studied endoscopic treatment option and provides good symptomatic benefit 1, 2, 5, 7
- This approach is particularly effective for patients who fail pharmacological therapy 7
- Be aware that post-injection gastroesophageal reflux may develop and requires monitoring 5
Esophageal dilation should be performed only if associated strictures or narrowing are present, using balloon dilation or wire-guided bougie dilators 1, 2
Behavioral Interventions as Adjunctive Therapy
Implement cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, or diaphragmatic breathing for patients with associated hypervigilance or hypersensitivity 1, 2
Advanced Treatment for Refractory Cases
For patients who remain symptomatic despite the above measures:
Per-oral endoscopic myotomy (POEM) is the preferred advanced treatment for type III achalasia (achalasia with spasm) and may benefit select cases of refractory distal esophageal spasm 1, 2, 5
- POEM should only be performed by experienced physicians in high-volume centers, as 20-40 procedures are needed to achieve competence 1, 2
- Counsel patients about high risk of post-POEM reflux esophagitis requiring potential indefinite PPI therapy and/or surveillance endoscopy 1, 2
Heller myotomy combined with fundoplication remains an alternative for rare refractory patients 5, 3
Critical Pitfalls to Avoid
Do not use metoclopramide as monotherapy or adjunctive therapy, as evidence shows it is ineffective or causes more harm than benefit 1
Failure to identify and treat concurrent GERD will lead to persistent symptoms despite appropriate spasm-directed therapy 1, 5, 3
Do not overlook eosinophilic esophagitis, which presents with similar symptoms but requires different management (topical steroids and dietary modification) 1, 2
Avoid assuming symptoms are purely functional without excluding structural pathology through endoscopy, as malignancy and inflammatory conditions must be ruled out 2, 3