Esophageal spasm: Causes & Risk factors

Esophageal contractions should be present, but they should also be well coordinated, moving food through the esophagus and into the stomach. It is easy to understand that they are very important because they can prevent food from reaching the stomach, leaving it stuck in the esophagus. Esophageal spasms are, on the other hand, a very rare condition.[1]

The problem is that symptoms which may suggest an esophageal spasm are often the result of some other condition such as [1]:

• Gastro-esophageal reflux disease (GERD)
• Achalasia — a problem with the nervous system in which the lower esophageal sphincter (LES) doesn't work properly
• Anxiety or panic attacks

The cause of esophageal spasms is unknown. Many doctors believe an esophageal spasm results from a disruption of the nerve activity that coordinates the swallowing action of the esophagus. Very hot or very cold foods may trigger spasms in some people. [2]

Types Of Esophageal Spasms

Generally speaking, esophageal spasms can be subdivided into two distinct entities [3]:

Diffuse esophageal spasm (DES), in which contractions are uncoordinated. Several segments of the esophagus contract simultaneously, preventing the propagation of food.

Nutcracker esophagus, in which contractions proceed in a coordinated manner, but the amplitude is excessive.

The Most Common Symptoms Of Esophageal Spasms

• Chest pain - Most people with esophageal spasms have chest pain that may spread outward to the arms, back, neck, or jaw. This pain can feel similar to a heart attack.
• Difficulty or inability to swallow food or liquid
• Pain when swallowing
• The feeling that food is caught in the center of the chest
• A burning sensation in the chest (heartburn) [2]

Possible causes of esophageal spasms

Although the etiology of esophageal spasms is unknown, there are several possible scenarios:

• An increased release of acetylcholine appears to be a factor, but the triggering event is not known.
• Gastric reflux or a primary nerve or motor disorder.
• Microvascular compression of the vagus nerve in the brainstem has been demonstrated in recent research as a possible triggering event.
• Hot or cold foods [2]

Esophagus Physiology 

The esophagus is comprised of two layers of muscle, the inner circular, and the outer longitudinal layers. The esophagus can be divided into three zones, each with separate anatomy and physiology. [4]

Upper zone

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

The middle zone is made of striated and smooth muscles. It is made of the inner circular muscle layer and the outer longitudinal muscle layer which work in conjunction to propel the food.

Lower zone

The lower segment is the lower esophageal sphincter. This circular muscle is a thickening of the smooth muscle that is contracted to prevent reflux. The pressure in the LES should normally be 15-25 mm Hg.

Esophageal Muscles

Upper esophageal sphincter 

When functioning properly, the esophagus can detect the presence of food at the upper esophageal sphincter. It coordinates progression of food down the esophagus to the stomach. Evaluation of the upper esophageal sphincter reveals constant spiking activity. When a person starts swallowing food, the tonic contraction of the UES is inhibited, opening the UES to allow passage of food. The longitudinal muscles must contract to propel the food, which is followed immediately by the contraction of the circular muscles. That’s how the initial wave starts, propelling the food down to the middle zone.

Esophageal middle zone 

The middle zone of the esophagus propels the food from the upper zone to the lower zone. This segment consists of two muscle layers, an inner circular and outer longitudinal layer.

There is only one but a 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, food bolus cannot progress.

There are two forces that propel food:

• First, gravity pulls the food caudally.
• Second, the organized contractions of the muscles propel the food caudally. 

Lower esophageal sphincter 

The 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 and allow a food bolus to pass is termed achalasia.

Diagnosis Of Esophageal Spasms

Physical examination and patient history 

A doctor can often determine the cause of esophageal spasms 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.

Laboratory studies

Laboratory 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 levels 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 test

It is important to point out that barium swallow is the best possible imaging study to help in the diagnosis of an esophageal spasm. Barium swallow images show typical appearance of multiple simultaneous contractions. This is often referred to as a corkscrew appearance.

CT scan

The 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 helps to rule out some of these conditions.

Even in patients with symptoms of esophageal spasms, 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. 

Manometry

Manometry in patients with nutcracker esophagus demonstrates contractions that progress in an orderly manner, with an excessive amplitude. Amplitude greater than two standard deviations above the normal value is considered diagnostic for nutcracker esophagus.

Endoscopy 

An endoscopy is a very useful 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. [5]

Treatment of esophageal spasms

Esophageal spasms are difficult to treat.

Medications

Medications that are used commonly are:

Calcium channel blockers

These drugs can reduce the amplitude of the contractions. In patients with a 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.

Nitrates

Nitrates have also 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.

Some patients have tried sublingual nitroglycerin for acute symptoms of esophageal spasm.

Tricyclic antidepressants 

These medications, specifically imipramine, have been shown to decrease chest pain with no apparent cause on an angiogram. 

Balloon Dilatation

This method is commonly used to treat achalasia, but it has been used to treat esophageal spasms and nutcracker esophagus too. The problem is that studies are limited, the relief is not uniform, and symptoms often recur.

Surgical Treatment

Myotomy 

This operation relieves symptoms eliminating the effectiveness of the contractions by cutting down some layers of muscles. Traditionally, a thoracotomy, the opening of the chest, was required to obtain access to the esophagus, but now, a thoracoscopic approach can be used. Myotomy is, although very radical, also very effective in treating esophageal spasms. The myotomy should extend to the entire length of the involved segment, which should be determined preoperatively with manometry. The problem is that myotomy usually reduces the amplitude of the contractions but does not consistently improve symptoms, especially if the primary complaint is pain.

Anti-reflux procedure 

The anti-reflux procedure should be performed concomitantly, using either a partial wrap or a floppy wrap.

Myotomy should be used with caution in patients with a nutcracker esophagus because it may worsen the symptoms.

Esophagectomy 

As a last possible option, removal of the esophagus (called esophagectomy) can be used to relieve symptoms. The esophagus is usually completely removed, except 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, it should be performed only after other treatments have been exhausted. It is a very complicated procedure that sometimes lasts for a couple of hours. [2, 3, 4, 5, 6]

In Conclusion 

The first line of defense should be recognizing symptoms. If a doctor diagnoses gastro-oesophageal reflux, a patient should be treated for the specific underlying cause which should simultaneously ease the esophagus spasms. 

The first treatment option, found in your kitchen cabinet, is peppermint oil. Mixing a small amount of peppermint oil in water makes the muscles of the esophagus contract normally again. [6]  

Several studies have documented improvements with proton-pump inhibitors, nitrates, calcium-channel blockers and tricyclic antidepressants or serotonin reuptake inhibitors. [5] 

Small case series reported benefits after botulinum toxin injections [7], pneumatic dilatations [8] and myotomies [9].

However, uncertainty still persists regarding the optimal management of oesophageal spasm.

As a general guideline, doctors should try acid suppression, muscle relaxants, and visceral analgetics first and botulinum toxin (botox) injections should be reserved for patients who do not respond to the first line of treatment. Pneumatic dilatations or myotomies are quite radical and should be presented only to the patients who do not respond to the treatment suggested above.