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May 23, 2006
Esophageal spasm: Causes & Risk factors
by SirGan
 Esophageal spasms is one condition characterized by irregular, uncoordinated, and sometimes powerful contractions of the esophagus, the tube that carries food from the mouth to the stomach. Normally, these contractions should be present but they are well coordinated, moving the food through the esophagus and into the stomach. So, it is reasonable that they are very important because they can prevent food from reaching the stomach, leaving it stuck in the esophagus.Esophageal spasms are very rare condition. Problem is that symptoms which may suggest an esophageal spasm are often result of another condition such as:
The cause of esophageal spasm is unknown. Many doctors believe it results from a disruption of the nerve activity that coordinates the swallowing action of the esophagus.
Types of esophageal spasmsBroadly, esophageal spasm can be subdivided into 2 distinct entities,
Most common symptoms
Possible causes of esophageal spasmsAlthough the etiology of esophageal spasm is unknown, there are several possible scenarios such as:
Esophagus physiologyThe esophagus is comprised of 2 layers of muscle, the inner circular and the outer longitudinal layers. The esophagus can be divided into 3 zones, each with separate anatomy and physiology.
Made entirely of striated muscle, this zone initiates the contractions that propel the food down the esophagus. The upper esophageal sphincter is located in the upper zone. It prevents food from returning the same way up!
Middle zone is made of striated and smooth muscles. There are inner circular muscle layer and the outer longitudinal muscle layer which work in conjunction to propel the food.
The lower segment is the lower esophageal sphincter. This sphincter-circular muscle is a thickening of the smooth muscle that is contracted to prevent reflux. Normally- the pressure in the LES usually is 15-25 mm Hg.
Esophageal musclesUpper esophageal sphincterWhen functioning properly, the esophagus can detect the presence of a food at the upper esophageal sphincter. Then, it coordinates progression of the food down the esophagus to the stomach. Evaluation of the upper esophageal sphincter reveals constant spiking activity. When the person is starting to swallow food- the tonic contraction of the UES is inhibited, opening the UES to allow passage of food. To propel the food, the longitudinal muscles must contract, followed immediately by contraction of the circular muscles. That’s how the initial wave starts, propelling the food down to the middle zone.
Esophageal middle zoneLogically, the middle zone of the esophagus propels the food from the upper zone to the lower zone. This segment consists of 2 muscle layers, an inner circular and outer longitudinal layer.
There is only one but very important difference - in the middle zone, the striated muscle transitions to smooth, or involuntary, muscle. If the muscle contraction of this part of esophagus is not orderly, the food bolus cannot progress. There are two forces that propel the food:
Lower esophageal sphincterThe lower zone is comprised of the lower esophageal sphincter. This is a condensation of the smooth muscles. This muscle is contracted and must relax to allow food to pass. Failure of the LES to relax to allow a food bolus to pass is termed achalasia.
Diagnosis of esophageal spasmsPhysical examination and patient’s historyDoctor can often determine the cause of esophageal spasm by doing a physical exam and asking a patient a series of questions. These include questions about what foods or liquids trigger symptoms, where it feels like food gets stuck, other symptoms or conditions she or he may have, and whether a patient is taking medications for them.
Laboratory studiesLaboratory evaluation usually does not help in the diagnosis if patients' history and physical examination are unremarkable for other diseases mentioned in the differential diagnosis.
Blood sugar and hemoglobin A1C should be checked to rule out diabetes. However, patients can have esophageal spasm and diabetes concomitantly. The findings discovered by monitoring a patient's pH can demonstrate reflux, which can present with somewhat similar symptoms.
Barium swallow testIt is important to point out that barium swallow is the best possible imaging study to help in the diagnosis of esophageal spasm. Upon barium swallow images show characteristic appearance of multiple simultaneous contractions. This often is referred to as a corkscrew appearance.
CT scanThe hypertrophy of the muscle wall is the cause of the increased thickness that is observed on CT scan images. The normal thickness of the esophagus is less than 3 mm and in cases of esophageal spasms it is much thicker!
Many other disease processes, including malignancy, can cause thickening of the esophagus that can be seen and that’s why it also help to rule out some of these conditions.
Even in patients with symptoms of esophageal spasm, thickening seen on CT scan images should not be dismissed as muscular hypertrophy secondary to the esophageal spasms without further investigation. That’s why-further analysis is necessary!
ManometryManometry in patients with nutcracker esophagus demonstrates contractions that progress in an orderly manner, but the amplitude of the contraction is excessive. Amplitude greater than 2 standard deviations above the normal value is considered diagnostic for nutcracker esophagus.
EndoscopyIt is very good diagnostic tool to examine the condition and function of the esophagus. Tests measure acid levels in the esophagus as well as the strength and pattern of muscle contractions in the esophagus.
Treatment of esophageal spasmsEsophageal spasms are difficult to treat.
MedicationsMedications that are commonly being used are:
These medications can reduce the amplitude of the contractions. In patients with nutcracker esophagus, calcium channel blockers effectively reduce the amplitude of the contractions, but the chest pain may not always be reduced. Traditionally, calcium channel blockers were thought to decrease the contractions.
They are also have been used with some success. The mechanism of action is unknown but may be related to decreasing vasospasm in the brainstem, similar to calcium channel blockers.
These medications, specifically imipramine, have been shown to decrease chest pain with no apparent cause on angiogram.
Balloon dilatationThis method has been commonly is used for achalasia, but it has been used to treat esophageal spasms and nutcracker esophagus. Problem is that the studies are small, the relief is not uniform, and symptoms recur.
Surgical treatment
This operation relieves symptoms by eliminating the effectiveness of the contractions by cutting down some layers of muscles. Traditionally, a thoracotomy-opening of the chest, was required to obtain access to the esophagus, but now, a thoracoscopic approach can be used. Myotomy is, although very radial, also very effective for treating esophageal spasms. The myotomy should extend the entire length of the involved segment, which should be determined preoperatively with manometry. Problem is that myotomy usually reduces the amplitude of the contractions, but this does not consistently improve symptoms, especially if the primary complaint is pain.
Anti-reflux procedure should be performed concomitantly, by either a partial wrap or a floppy wrap.
Myotomy should be used with caution in patients with nutcracker esophagus because it may worsen the symptoms.
As a last possible option, esophagectomy- removal of the esophagus can be used to relieve symptoms. The esophagus is usually removed completely accept the extreme upper part and the stomach, small intestine, or colon is used to restore the continuity of the GI tract. Morbidity and mortality of esophagectomy are substantial; therefore, this should be performed only after other treatments have been exhausted. It is very complicated procedure that sometimes last for couple of hours!
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