Esophageal Spasm

How the esophagus normally works

When you swallow, the esophagus contracts in a coordinated wave (peristalsis) that pushes food down, while the lower esophageal sphincter at the bottom relaxes to let food into the stomach. In esophageal spasm, this sequence breaks down. The nerves that coordinate the muscle malfunction, so segments contract simultaneously or too forcefully.

Types of esophageal spasm

These are diagnosed using the Chicago Classification on high-resolution manometry. They are related to achalasia, in which the lower sphincter fails to relax, and some spasms evolve into achalasia over time.

Symptoms

• Chest pain: sudden, intense, squeezing or crushing pain behind the breastbone, lasting from seconds to minutes or longer. It may spread to the neck, jaw, back or arms. It can happen during meals or at rest and even wake you from sleep.
• Difficulty swallowing (dysphagia) for both solids and liquids, often intermittent.
• The feeling of something stuck in the chest or throat.
• Regurgitation of food or liquid.
• Heartburn, if reflux is also present.

Esophageal spasm vs heart attack

The pain of esophageal spasm can be indistinguishable from angina or a heart attack, and both can be relieved by nitroglycerin. New chest pain should always be treated as a possible heart problem until doctors have ruled that out. Clues that suggest the esophagus include pain linked to swallowing, food sticking, pain triggered by hot or cold drinks, and normal heart tests, but these do not exclude heart disease.

Causes and triggers

The cause is not fully understood. It involves dysfunction of the nerves in the esophageal wall. Factors linked with spasms include:

• Gastroesophageal reflux disease (GERD): reflux is present in many people with spasms and may trigger them
• Very hot or very cold food and drinks
• Eating quickly or swallowing large bites
• Stress and anxiety
• Opioid medicines, which can cause spasm-like contractions
• Older age

Diagnosis

After heart causes are excluded with an ECG, blood tests and sometimes stress testing, doctors evaluate the esophagus:

1. Upper endoscopy: a camera checks for inflammation (esophagitis), strictures, tumors or eosinophilic esophagitis, which can cause similar symptoms.
2. High-resolution esophageal manometry: a thin tube through the nose measures pressure along the esophagus as you swallow sips of water. It is the key test that confirms spasm and its type.
3. Barium swallow: X-rays after drinking contrast may show a "corkscrew" or "rosary bead" pattern in distal esophageal spasm.
4. pH monitoring: measures acid reflux over 24 to 96 hours.

Treatment

Treat reflux

If reflux is present, a proton pump inhibitor (PPI) such as omeprazole often reduces spasms. Avoiding late meals and raising the head of the bed help too.

Lifestyle measures

• Avoid very hot or very cold food and drinks
• Eat slowly, take small bites and chew well
• Identify and limit personal trigger foods
• Manage stress with relaxation techniques
• Sipping warm water during an episode helps some people

Medicines

• Smooth muscle relaxants: calcium channel blockers (such as diltiazem) or nitrates may reduce contraction strength.
• Low-dose antidepressants: tricyclics (such as amitriptyline or imipramine) or trazodone reduce the esophagus's pain sensitivity and are often the most helpful for chest pain.
• Peppermint oil: may relax the esophageal muscle in some people.

Procedures

• Botulinum toxin (Botox) injection: injected into the esophageal muscle during endoscopy, it relaxes the muscle for several months.
• Esophageal dilation: stretching, used if the lower sphincter is also involved.
• Peroral endoscopic myotomy (POEM): an endoscopic procedure that cuts the overactive muscle layer. It is used for severe, persistent symptoms that do not respond to other treatment.
• Surgical myotomy: rarely needed.

Outlook

Esophageal spasm is not life-threatening, and for many people symptoms are occasional and manageable. Treating reflux and using medicines to reduce pain sensitivity help most people. Severe cases respond to procedures such as POEM. A small number of people develop achalasia over time, so persistent swallowing problems should be followed up.

Frequently asked questions

What does an esophageal spasm feel like?

It usually feels like a sudden, intense squeezing or crushing pain behind the breastbone, sometimes spreading to the neck, jaw or back. Many people also feel food sticking in the chest or have trouble swallowing. Episodes can last seconds to minutes.

How can I tell an esophageal spasm from a heart attack?

You cannot reliably tell them apart from symptoms alone. Both cause squeezing chest pain and both may improve with nitroglycerin. Any new or unexplained chest pain should be treated as a possible heart attack. Call 911 and let doctors rule out heart causes first.

What triggers esophageal spasms?

Common triggers include very hot or cold food and drinks, acid reflux, eating quickly or swallowing large bites, stress, and some medicines such as opioids. Triggers vary between people.

How do you stop an esophageal spasm?

During an episode, sipping warm water, sitting upright and staying calm may help. Long term, treating reflux, avoiding triggers, and medicines such as calcium channel blockers or low-dose antidepressants reduce attacks. Severe cases may need Botox or POEM.

Is esophageal spasm dangerous?

It is painful and distressing but not usually dangerous. The main risks are missing a heart problem that causes similar pain, weight loss from swallowing difficulty, and food becoming stuck. A doctor should evaluate recurring symptoms.