Esophageal Spasm with Symptomatic Relief from Antacid
This patient's vigorous shaking spells that resolve with warm water and Maalox strongly suggest esophageal spasm, not a neurological or metabolic disorder. The immediate relief from an antacid-containing beverage is pathognomonic for an esophageal origin rather than true seizures, shivering, or other systemic causes.
Clinical Reasoning
The key diagnostic feature here is the rapid symptom resolution with warm liquid plus antacid 1. This response pattern is inconsistent with:
- Seizure activity – would not respond to antacids and typically requires anticonvulsant medications 1
- Shivering from hypothermia – requires rewarming and does not respond to antacids 1
- Metabolic disturbances (hypocalcemia, hypokalemia, hypomagnesemia) – would require specific electrolyte replacement and would not resolve within minutes of drinking Maalox 2, 3
- Orthostatic hypotension or vasovagal syncope – these conditions respond to fluid resuscitation and positional changes, not antacids 1
Esophageal Spasm Characteristics
Esophageal spasm presents with sudden, severe chest discomfort or a sensation of vigorous internal movement that patients may describe as "shaking" or "spasms." The condition is characterized by:
- Uncoordinated, high-amplitude contractions of the esophageal smooth muscle
- Symptoms triggered or worsened by gastroesophageal reflux
- Rapid relief with warm liquids (which relax esophageal smooth muscle) and antacids (which neutralize acid triggering the spasm) 4, 5, 6
The magnesium hydroxide component in Maalox provides additional smooth muscle relaxation beyond simple acid neutralization 4, 6.
Recommended Diagnostic Approach
Obtain a detailed description of the "shaking" episodes, specifically asking about:
- Chest or upper abdominal location of the sensation (rather than whole-body shaking) 1
- Relationship to meals, particularly large meals or acidic foods
- Presence of dysphagia, odynophagia, or heartburn between episodes
- Absence of loss of consciousness, tongue biting, or post-event confusion (which would suggest seizures) 1
Perform an electrocardiogram to exclude cardiac arrhythmias that could present with palpitations or chest discomfort 1.
Measure serum calcium, magnesium, and potassium to exclude metabolic causes of muscle spasm, though the rapid response to antacids makes these unlikely 1, 2, 3.
Definitive Management
Initiate a proton pump inhibitor (PPI) once daily as first-line therapy for presumed esophageal spasm triggered by acid reflux 1.
Recommend continued use of liquid antacids (Maalox or equivalent) for acute symptom relief, taken as needed when episodes occur 4, 5, 6.
Advise dietary modifications including:
- Avoiding large meals, particularly before bedtime 1, 7
- Eliminating trigger foods (caffeine, alcohol, acidic foods, carbonated beverages) 1, 7
- Eating smaller, more frequent meals 1, 7
If symptoms persist despite PPI therapy, refer for esophageal manometry to confirm the diagnosis of esophageal spasm and guide further treatment, which may include calcium channel blockers or nitrates for smooth muscle relaxation 1.
Critical Pitfalls to Avoid
Do not assume these are seizures simply because the patient describes them as "shaking spells" – the immediate response to antacids excludes a primary neurological etiology 1.
Do not pursue extensive neurological workup (EEG, brain imaging) before considering gastrointestinal causes, given the clear relationship between symptoms and antacid use 1.
Do not overlook cardiac causes – obtain at minimum a 12-lead ECG to exclude arrhythmias, particularly in a 40-year-old man 1.
Recognize that the magnesium and aluminum in Maalox can affect absorption of other medications if the patient is taking concurrent drugs, particularly fluoroquinolones or medications requiring consistent absorption 5.