Esophageal Spasm Management

Diagnosis

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, including esophageal spasm, in patients with symptoms of esophageal dysfunction, and should be used in conjunction with endoscopy to rule out structural abnormalities and assess for erosive esophagitis, with consideration of pH monitoring to evaluate for concomitant GERD 1, 2

The American Gastroenterological Association and the American College of Gastroenterology recommend starting with single-dose proton pump inhibitor (PPI) therapy for 4-8 weeks in patients with esophageal spasm, with the option to increase to twice daily dosing or switch to a more effective acid suppressive agent if there is an inadequate response, as GERD frequently coexists with esophageal spasm and may contribute to symptoms 2
Baclofen may be considered for patients with regurgitation or belch predominant symptoms, as an adjunct to PPI therapy 2
Low-dose antidepressants (tricyclic agents or SSRIs) can be useful for visceral hypersensitivity and pain component, and should be considered for patients with esophageal hypervigilance or hypersensitivity 2, 3

Hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies may benefit patients with functional heartburn or reflux disease associated with esophageal hypervigilance and reflux hypersensitivity 2
Peroral endoscopic myotomy (POEM) is an emerging technique that may be beneficial for esophageal spasm, particularly effective for type III achalasia which has spastic components, allowing for extended myotomy that can address the full length of spastic segments 4

Type III achalasia (associated with persistent peristalsis with spasm) has the poorest response to all treatments compared to types I and II, and treatment decisions should be based on local expertise, therapeutic availability, and patient choice rather than subtype 1
Metoclopramide should be avoided as monotherapy or adjunctive therapy in patients with esophageal syndromes, due to fair evidence of being ineffective or having harms that outweigh benefits (Grade D recommendation) 5
Heller myotomy (usually combined with fundoplication) is reserved for very severe symptoms refractory to pharmacologic and endoscopic treatment, and should only be considered after comprehensive evaluation and confirmation of diagnosis 4
A stepwise approach to treatment is recommended, starting with pharmacotherapy, followed by endoscopic botulinum toxin injection for refractory cases, and surgical interventions as a last resort for severe cases unresponsive to other treatments 2