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.