Esophageal Spasm

Oesophageal spasm (distal oesophageal spasm, DES) is a motility disorder with premature (rapid) contractions of the distal oesophagus, causing dysphagia and chest pain.

• Defined by high resolution manometry (Chicago classification): at least 20% of swallows with premature contractions (distal latency under 4.5 seconds), with normal lower oesophageal sphincter relaxation (integrated relaxation pressure normal).
• Rare; prevalence 1 in 100,000; women more affected, middle aged.
• Mechanism: impaired inhibitory (nitric oxide) neuronal function with excessive excitatory (cholinergic) activity.
• Associations: gastro oesophageal reflux disease, opioids (can induce), diabetes, obstruction, anxiety.
• Can progress to type III achalasia in some patients.

• Intermittent chest pain, non cardiac, retrosternal, may radiate to back, neck, arms and mimic angina; may be precipitated by hot or cold liquids, stress, rapid eating.
• Dysphagia for both solids and liquids, regurgitation, globus.
• Pain may be relieved by nitroglycerin.
• Differential diagnosis: coronary disease (must exclude first), reflux, achalasia, eosinophilic oesophagitis, jackhammer oesophagus, anxiety.

• Exclude cardiac causes: ECG, troponin, stress testing or angiography.
• Upper endoscopy to exclude obstruction, eosinophilic oesophagitis, reflux oesophagitis, malignancy (biopsy).
• High resolution oesophageal manometry: premature contractions with distal latency under 4.5 seconds in 20% or more of swallows, normal integrated relaxation pressure. Rule out achalasia type III.
• Barium oesophagram: corkscrew oesophagus, rosary bead pattern (not specific).
• Timed barium oesophagram and endoluminal functional lumen imaging probe (EndoFLIP) in selected cases.
• 24 hour pH impedance monitoring for coexisting reflux.

• Reassure about the benign cause after exclusion of cardiac disease.
• Treat reflux: PPI (omeprazole 20 to 40 mg twice daily for 8 weeks).
• Smooth muscle relaxants: diltiazem 60 to 120 mg three times daily or nifedipine 10 to 20 mg three times daily sublingual before meals, isosorbide dinitrate 5 to 10 mg before meals, sildenafil 25 to 50 mg (nitric oxide pathway), peppermint oil 0.2 mL capsules.
• Neuromodulators: low dose tricyclic (imipramine 25 to 50 mg at night, amitriptyline 10 to 25 mg), trazodone 50 to 100 mg, sertraline for visceral hypersensitivity and anxiety; cognitive behavioural therapy and hypnotherapy.
• Botulinum toxin injection (100 units distributed in distal oesophagus, benefit in 70% short term).
• Peroral endoscopic myotomy (POEM) with an extended distal oesophageal myotomy for refractory, severe disease (success 80 to 90%).
• Pneumatic dilation or surgical myotomy have lower efficacy.
• Avoid triggers (extreme temperatures, carbonated drinks), eat slowly.
• Opioid induced spasm: reduce or stop opioid.