What is the recommended treatment for a patient with esophageal spasm, particularly one with a history of anxiety or panic disorders?

Treatment of Esophageal Spasm in Patients with Anxiety or Panic Disorders

For patients with esophageal spasm and comorbid anxiety or panic disorders, benzodiazepines like Valium (diazepam) may provide symptomatic benefit through their centrally-acting anxiolytic effects, but SSRIs (particularly fluoxetine or citalopram) are the preferred first-line neuromodulators, combined with calcium channel blockers (diltiazem) for direct smooth muscle relaxation. 1, 2

Diagnostic Confirmation First

Before initiating treatment, confirm the diagnosis of esophageal spasm through:

• Esophageal manometry showing simultaneous or premature contractions (>10% of wet swallows) intermixed with normal peristalsis 3, 4
• Upper endoscopy to exclude structural causes, erosive esophagitis, and malignancy 5
• Barium esophagogram as a complementary diagnostic approach, recognizing that the intermittent nature of spasm makes it nearly impossible to completely rule out 4

Pharmacologic Treatment Algorithm

First-Line Therapy

Calcium channel blockers are the primary smooth muscle relaxants:

• Diltiazem combined with omeprazole significantly reduces Eckardt scores (mean decrease 2.57) and heartburn scores (mean decrease 0.89) 6
• These agents reduce esophageal contractile force directly at the smooth muscle level 1

Neuromodulator Selection Based on Psychiatric Comorbidity

For patients with documented anxiety or panic disorders:

• SSRIs are preferred over benzodiazepines as first-line neuromodulators 7, 8

  • Fluoxetine (typically 20-40 mg daily) combined with omeprazole shows comparable efficacy to diltiazem, with mean Eckardt score reduction of 3.18 and heartburn score reduction of 1.03 6
  • Citalopram 20 mg daily is the most evidence-based SSRI choice for esophageal hypersensitivity 7
  • Eight of nine patients (89%) with diffuse esophageal spasm improved with serotonin reuptake inhibitor antidepressants, compared to only one patient improving with nitrates alone 2

• Benzodiazepines (including Valium) have a role but are not first-line:

  • Evidence suggests "some clinical benefit from centrally acting drugs such as benzodiazepines" for the psychological component of esophageal symptoms 1
  • However, 56% of esophageal spasm patients have major psychiatric disorders requiring more definitive psychiatric treatment 2
  • Benzodiazepines carry risks of dependence, cognitive impairment, and do not address the underlying serotonin-mediated visceral hypersensitivity 7

Combination Therapy Approach

The optimal regimen combines:

1. Diltiazem (for smooth muscle relaxation) 6
2. SSRI (fluoxetine or citalopram for neuromodulation and anxiety) 6, 2
3. PPI (omeprazole, as GERD frequently coexists) 6, 3

This combination addresses both the motility disorder and the psychological component simultaneously.

Adjunctive Non-Pharmacologic Interventions

Cognitive Behavioral Therapy (CBT) should be pursued alongside pharmacotherapy:

• Referral to a cognitive-behavioral therapist is reasonable for patients with recurrent chest pain and psychological comorbidities 5
• CBT addresses esophageal hypervigilance and visceral hypersensitivity through psychological mechanisms 7
• Esophageal-directed hypnotherapy and diaphragmatic breathing exercises improve quality-of-life scores 7, 8

Critical Pitfalls and Caveats

Avoid these common errors:

• Do not use benzodiazepines as monotherapy when SSRIs can address both the anxiety disorder and esophageal hypersensitivity more definitively 7, 1, 2
• Do not combine multiple serotonergic agents (SSRI + SNRI) due to serotonin syndrome risk 8
• Recognize that neither fluoxetine nor diltiazem significantly improved psychological symptoms (hospital anxiety and depression scale scores) in clinical trials, emphasizing the need for concurrent psychiatric management 6
• Medical therapy results are generally poor for primary esophageal motility disorders, with clinical benefit often disappointing despite manometric improvements 1
• Consider that 56% of esophageal spasm patients have major psychiatric disorders requiring formal psychiatric evaluation and treatment beyond simple anxiolysis 2

Refractory Cases

For patients failing pharmacologic therapy:

• Botulinum toxin injection into the distal esophagus may be effective 3
• Heller myotomy with fundoplication or per oral endoscopic myotomy (POEM) for rare refractory patients 3