Oesophageal Spasm

Oesophageal spasm is a disorder of oesophageal motility. The oesophagus normally propels food from the upper oesophageal sphincter towards the stomach through waves of coordinated muscle contraction, or peristalsis. When these waves do not progress normally, oesophageal spasm can result.

Oesophageal spasm can be divided into:

• Diffuse oesophageal spasm: There are uncoordinated oesophageal contractions. Several sections of the oesophagus can contract at once and food is unable to pass normally. Dysphagia is common.
• Nutcracker oesophagus: The contractions are coordinated but with an excessive amplitude. Food can usually pass down the oesophagus but pain is common.¹

Either condition may be associated with gastro-oesophageal reflux which can exacerbate symptoms.

There is no clear aetiology. There may be a dysfunction of neural control, perhaps exacerbated by stress. Microvascular compression of the Vagus nerve in the brainstem has also been postulated.¹

• Exact prevalence unknown as symptoms may be mild and go undiagnosed
• Can affect all age groups but more common in elderly
• Women > men¹

Symptoms

Usually, symptoms occur less than once a month. In severe cases, they can occur several times a week or at every meal.

• Chest pain: Oesophageal spasm can cause episodes of severe, crushing central retrosternal pain. Because the heart and oesophagus are in such close proximity, distinguishing oesophageal from cardiac pain can be difficult² and oesophageal spasm is often initially diagnosed as angina pectoris. Oesophageal pain can be gripping, boring, pressing or stabbing. It is usually felt in the anterior chest, throat or epigastrium and can radiate to the neck, back or upper arms, as with cardiac chest pain.²
• Dysphagia: Intermittent dysphagia can cause patients to stop eating until symptoms abate. This can take from 30 minutes to several hours.
• Globus: The sensation of something stuck in throat/gullet.
• Regurgitation of food
• Heartburn: Occurs in 20% of patients.¹

Symptoms that suggest oesophageal, rather than cardiac, chest pain: Association with meals, dysphagia, relief by antacids, associated acid reflux, history of heartburn.²

• Myocardial ischaemia or infarction
• Oesophageal web, ring or stricture
• Oesophageal carcinoma
• Gastro-oesophageal reflux
• Oesophageal perforation/mediastinitis (acutely)
• Achalasia

Remember that oesophageal and cardiac problems can co-exist and diagnosis of one does not exclude the other. Also, any tests create anxiety and can lead to medical dependence.²

• Barium swallow: This can confirm the diagnosis of diffuse oesophageal spasm. There is a characteristic corkscrew oesophagus seen due to multiple simultaneous oesophageal contractions. Nutcracker oesophagus does not have such a characteristic appearance.
  
  
  
  
  
  
• Oesophageal manometry: 24 hour ambulatory manometry is preferable as spasm may be intermittent.^3,4 Diffuse oesophageal spasm shows intermittent, uncoordinated, simultaneous, prolonged, powerful oesophageal contractions induced by swallowing and interspersed with normal peristalsis. In nutcracker oesophagus there are co-coordinated peristaltic contractions of excessive force. For examples of oesophageal manometry traces demonstrating diffuse oesophageal spasm and nutcracker oesophagus, refer to the emedicine link below.
• Oesophageal pH studies: Allow assessment of concurrent gastro-oesophageal reflux disease.
• Oesophageal provocation tests: Edrophonium injected during oesophageal manometry can provoke abnormal contractions.² Limitations are that patients may anticipate symptoms and that it can produce contractions in a normal oesophagus.
• Ultrasound: High-frequency intraluminal ultrasound can assess the sensory and motor function of the oesophagus and help to differentiate diffuse oesophageal spasm and nutcracker oesophagus.¹
• Resting and exercise ECGs: These may be needed if the history contains features that could suggest a cardiac cause for the chest pain, especially if there are other cardiac risk factors (family history, smoking, hypercholesterolaemia etc.).

Non-drug

Reassurance that this is not heart disease and that no significant progression occurs is key. Dietary manipulation (including puréed diets) helps some but response is difficult to predict.

Drug

There is little evidence to show the most effective treatments and response to a drug appears to be largely idiosyncratic. Treatment is largely symptomatic.¹

• Calcium-channel blockers: Reduce amplitude of contractions.
• Nitrates: Mechanism of action unclear. May also confuse patients who have been told that their chest pain is not cardiac!
• Tricyclic antidepressants (specifically imipramine) and anxiolytics: Can reduce pain and associated anxiety. Benzodiazepines may be used but danger of addiction means they must be used with extreme caution.
• Endoscopic botulinum toxin injection: Gives transient but diminishing relief.
• Proton pump inhibitors: May be needed if there is associated reflux.

Surgical

• Endoscopic balloon dilatation of the gastro-oesophageal sphincter: Helps some patients, but unreliably.
• Oesophagomyotomy: Used rarely if the condition is very disabling.³ Laparoscopic Heller myotomy is thought to be the surgical treatment of choice for diffuse oesophageal spasm.⁵ Myotomy eliminates the effectiveness of contractions.¹
• Oesophagectomy: Very rarely used if symptoms are intractable.

There is no reliable surgical treatment for nutcracker oesophagus.⁵

• Mortality rate is virtually nil, but there can be much morbidity.
• Chest pain and dysphagia can lead to an inability to eat and subsequent malnutrition.
• There may be considerable associated psychological problems.
• With trial and error of medication, and use of surgical techniques in difficult/intractable cases, significant symptom relief should be achieved.