ConditionDigestive system
Diffuse Esophageal Spasm
Diffuse esophageal spasm (DES), also called distal esophageal spasm, is a rare disorder in which the muscles of the esophagus (food pipe) contract out of sequence instead of in a smooth wave. It causes episodes of squeezing chest pain and difficulty swallowing, often triggered by very hot or cold drinks or stress. The chest pain can feel like a heart attack, so heart causes must be ruled out first. Treatment includes treating reflux, muscle-relaxing medicines, and procedures for severe cases.
Also called: Distal esophageal spasm, esophageal spasm, DES, corkscrew esophagus
At a glance
- What it is
- Uncoordinated, premature contractions of the esophagus muscles.
- Main symptoms
- Squeezing chest pain, food or liquid feeling stuck, regurgitation.
- Triggers
- Very hot or cold drinks, large bites, stress, acid reflux.
- Diagnosis
- After excluding heart disease: endoscopy, barium swallow and high-resolution manometry.
- Treatment
- Reflux treatment, smooth-muscle relaxants, low-dose antidepressants, Botox, myotomy (POEM).
When to get help
Call 911 or go to the ER
- Chest pain with breathlessness, sweating, nausea, or pain spreading to the arm, jaw or back: call 911, because heart attack must be ruled out
- Food stuck in the chest that will not pass, with drooling or inability to swallow saliva
- Chest pain after vomiting, with fever or difficulty breathing
See a doctor within a day or two
- New episodes of chest pain that have not been assessed
- Difficulty swallowing with weight loss
Book a routine appointment
- Recurring chest pain or swallowing difficulty after heart causes have been ruled out
- Heartburn with chest pain episodes
What happens in esophageal spasm
When you swallow, the esophagus normally squeezes in a coordinated wave (peristalsis) that pushes food down into the stomach, while the valve at the bottom (the lower esophageal sphincter) relaxes. In diffuse esophageal spasm, the lower esophagus contracts too early and in several places at once. Food can be held up, and the strong contractions cause pain. On a barium X-ray, this can give the esophagus a "corkscrew" or "rosary bead" appearance.
A related condition, hypercontractile ("jackhammer") esophagus, involves very forceful but coordinated contractions. Both are esophageal motility disorders, as is achalasia, in which the lower valve fails to relax.
Symptoms
- Chest pain: squeezing, pressing or crushing pain behind the breastbone, lasting minutes to hours. It can spread to the back, arms or jaw, and may wake you at night.
- Difficulty swallowing both solids and liquids, often intermittent.
- A feeling of food stuck in the chest or throat.
- Regurgitation of food or liquid.
- Heartburn, if reflux coexists.
Symptoms come and go, and many people are symptom-free between episodes.
Esophageal spasm vs heart pain
Esophageal spasm pain can be indistinguishable from angina or a heart attack. Nitroglycerin can relieve both, so response to it does not tell them apart. Anyone with new chest pain needs heart causes ruled out first, especially with heart risk factors.
| Esophageal spasm | Heart pain | |
|---|---|---|
| Trigger | Swallowing, hot or cold drinks, stress | Exertion, emotional stress |
| Duration | Minutes to hours | Minutes (angina) or prolonged (heart attack) |
| Swallowing difficulty | Often | No |
| Relief | Sometimes with sips of water, antacids | Rest, nitroglycerin |
Causes and risk factors
The cause is not fully understood. It involves a problem with the nerves that coordinate esophageal muscle. Associated factors include:
- gastroesophageal reflux disease, which is present in many people with spasm
- anxiety and depression
- very hot or cold foods and drinks
- possibly opioid use
It is more common in people over 50 and slightly more common in women.
Diagnosis
- Heart evaluation: ECG, blood tests and sometimes stress testing to exclude heart disease.
- Upper endoscopy: a camera examination to rule out narrowing, inflammation (esophagitis), or cancer.
- Barium swallow: X-ray images while swallowing contrast liquid.
- High-resolution esophageal manometry: the key test. A thin tube measures pressure along the esophagus during swallows. DES is diagnosed when at least 20% of swallows show premature contractions with normal relaxation of the lower valve.
- pH monitoring: checks for acid reflux.
Treatment
First steps
- Treat reflux with a proton pump inhibitor; this alone can reduce spasms when GERD is a trigger.
- Avoid triggers: very hot or cold drinks, large bites, eating quickly.
- Warm water sipped at the start of an episode helps some people.
- Manage stress.
Medicines
- Smooth-muscle relaxants: calcium channel blockers (such as diltiazem) or nitrates before meals.
- Low-dose tricyclic antidepressants or trazodone: reduce the sensation of pain from the esophagus.
- Peppermint oil: may relax smooth muscle and is sometimes tried.
- Sildenafil: occasionally used.
Procedures
- Botulinum toxin (Botox) injections into the lower esophagus during endoscopy relax the muscle for several months.
- Peroral endoscopic myotomy (POEM): an endoscopic procedure that cuts the thickened muscle layer. It can give lasting relief in severe cases.
- Surgical myotomy: rarely needed.
Outlook
DES is not life-threatening and does not lead to cancer. Symptoms often fluctuate over time. Most people improve with reflux treatment and medicines, and severe cases often respond to endoscopic treatment. Rarely, DES progresses to achalasia.
Frequently asked questions
What does an esophageal spasm feel like?
It usually feels like a sudden squeezing or crushing pain in the chest, often with a sensation that food is stuck. Episodes can last minutes to hours and may be triggered by hot or cold drinks or eating.
Can esophageal spasms feel like a heart attack?
Yes. The pain can be very similar, including spreading to the arm or jaw. New or unexplained chest pain should always be treated as a possible heart problem first. Call 911 if you are unsure.
What triggers esophageal spasms?
Common triggers include very hot or very cold food and drinks, eating quickly, large bites, acid reflux and stress. Keeping a symptom diary can help identify your triggers.
How is diffuse esophageal spasm treated?
Treatment starts with acid reflux medicine and avoiding triggers. Muscle-relaxing medicines, low-dose antidepressants for pain, Botox injections, or a procedure called POEM may be used for persistent or severe symptoms.
Sources
This guide was written from current patient and clinical guidance, including:
- American College of Gastroenterology: Clinical Guidelines: Esophageal motility disorders (2020)
- Chicago Classification of esophageal motility disorders, version 4.0
- NIDDK: Esophageal motility disorders
- Mayo Clinic: Esophageal spasms
- MedlinePlus: Esophageal spasm