Esophageal Spasms: Clinical Description and Management

Clinical Presentation and Diagnosis

The American College of Cardiology notes that esophageal spasms are uncommon esophageal motility disorders characterized by abnormal, simultaneous contractions of the distal esophagus, presenting with squeezing retrosternal chest pain and/or dysphagia 1
Chest pain is the predominant symptom, often described as squeezing or spasm-like, which can mimic cardiac ischemia and requires careful cardiac evaluation before accepting an esophageal diagnosis, as recommended by the American College of Cardiology 1, 2
The American College of Cardiology recommends that cardiac evaluation must be completed first given the substantially greater morbidity and mortality of ischemic heart disease compared to esophageal disorders 2, 3

The American Gastroenterological Association recommends smooth muscle relaxants, neuromodulators, and acid suppression as first-line pharmacological approaches for esophageal spasms 4
Proton pump inhibitors (PPIs) are recommended as initial therapy, especially when symptoms overlap with GERD, according to the American Gastroenterological Association 4
The American Gastroenterological Association suggests that neuromodulators such as tricyclic antidepressants or SSRIs are effective for esophageal hypersensitivity and visceral analgesia 4
Baclofen (GABA-B agonist) may be effective for regurgitation and belch-predominant symptoms, though CNS and GI side effects can occur, as noted by the American Gastroenterological Association 4
Metoclopramide should NOT be used as it is ineffective and potential harms outweigh benefits, according to the American Gastroenterological Association 4

High-resolution manometry (HRM) is essential for accurate diagnosis, with modern criteria requiring at least two premature contractions (distal latency <4.5 seconds) in the context of normal lower esophageal sphincter relaxation, as recommended by the American Gastroenterological Association 5
Complete evaluation should include esophagogram, endoscopy, manometry, and pH monitoring to establish comprehensive diagnosis, according to the American Gastroenterological Association 5
Ambulatory impedance-pH monitoring may be used to definitively rule out GERD if diagnosis remains unclear, as suggested by the American Gastroenterological Association 4

Per-oral endoscopic myotomy (POEM) is the preferred surgical approach for refractory distal esophageal spasm, with success rates >90%, according to the American Gastroenterological Association 5, 4
POEM provides the advantage of unlimited proximal extension of myotomy compared to laparoscopic approaches, as noted by the American Gastroenterological Association 5

Cognitive behavioral therapy (CBT), esophageal-directed hypnotherapy, and diaphragmatic breathing can be effective for patients with associated hypervigilance or hypersensitivity, according to the American Gastroenterological Association 5, 4

Videofluoroscopy/barium studies have 80-89% sensitivity and 79-91% specificity for diagnosing esophageal motility disorders, including diffuse esophageal spasm, according to the American College of Radiology 6
Biphasic esophagram provides superior detection of both mucosal lesions and motility abnormalities, as recommended by the American College of Radiology 6
Barium studies may occasionally reveal dysmotility not detected on manometry, highlighting the importance of complementary testing 6
Endoscopy is essential to exclude structural causes, including tumors, strictures, rings, eosinophilic esophagitis, and infectious esophagitis, as stated by the American Gastroenterological Association 7, 8
At least 5-6 biopsies should be obtained, even if mucosa appears normal endoscopically, to evaluate for eosinophilic esophagitis, as recommended by the American Gastroenterological Association 7, 8
High-resolution manometry has superior sensitivity to conventional manometry in recognizing atypical cases of achalasia and distal esophageal spasm, according to the American Gastroenterological Association 7, 8
Manometry serves to localize the lower esophageal sphincter for potential subsequent pH monitoring and evaluate peristaltic function, as stated by the American Gastroenterological Association 7, 8

Query for infectious and inflammatory causes of secondary achalasia, including recent COVID infections, Chagas disease risk, and eosinophilic disease, as recommended by the American Gastroenterological Association 9, 10
Consider systemic sclerosis, mixed connective tissue disease, SLE, or Sjögren's disease as these can cause esophageal dysmotility, according to the American College of Gastroenterology 9, 10
In immunocompromised patients, consider infectious esophagitis (Candida, HSV, CMV), as stated by the American College of Radiology and the American Gastroenterological Association 6, 10
Functional Luminal Impedance Planimetry (FLIP) can be a useful adjunct test, particularly when diagnosis is equivocal on HRM, as recommended by the American Gastroenterological Association 11, 12

Do not rely on single diagnostic test - barium studies and manometry are complementary, and one may reveal abnormalities missed by the other, as stated by the American College of Radiology 6
Do not skip biopsies even with normal-appearing mucosa - eosinophilic esophagitis can be latent and present in up to 9% of patients with dysphagia, according to the World Journal of Emergency Surgery 13