Oesophageal Spasm

Pathology

• Characterised by uncontrollable, intermittent spasms of the oesophagus.

• Exact cause unknown, but can be linked to oesophageal dysmotility disorders and triggered by stress, cold/hot foods, or acid reflux.

Presentation

• Retrosternal, acute-onset, sharp chest pains which can mimic angina.

• Pain may radiate to the back.

• Often accompanied by dysphagia (difficulty swallowing).

• Normal cardiac investigations help exclude cardiac causes of chest pain.

• Notably, pain relief with nitroglycerin or calcium channel blockers supports a diagnosis of oesophageal spasm.

Treatment

1. Proton Pump Inhibitors (PPIs)

   • Pantoprazole 40 mg daily is an initial choice, especially if GORD or acid reflux is suspected or coexisting.

   • PPIs can help if acid-triggered spasm is relevant.

2. Lifestyle Measures

   • Avoid extremes of food temperature (cold or very hot).

   • Drink warm water at the start of an episode to help relax the oesophagus.

   • Manage any reflux triggers: Weight reduction, avoiding caffeine, alcohol, large meals.

   • Stress management techniques (e.g. relaxation therapy).

3. Symptomatic Relief

   • Sublingual Glyceryl Trinitrate (400 mcg spray) PRN can relieve spasm.

   • Calcium Channel Blockers (e.g. nifedipine, diltiazem) orally to reduce oesophageal muscle hypercontractility.

4. Further Management

   • If unresponsive to standard treatments, consider oesophageal manometry to confirm diagnosis of spasm versus other motility disorders (e.g. diffuse oesophageal spasm, nutcracker oesophagus).

   • Referral to gastroenterologist if refractory: Options may include botulinum toxin injection into the oesophagus or myotomy in selected severe cases.

Additional Notes

• First-line: Treat for possible coexisting GORD with PPIs.

• Reassure patients chest pain is non-cardiac if thorough cardiac workup is normal.

• Avoid triggers (cold drinks, large meals, stress) and adopt a healthy lifestyle.

• Confirm diagnosis by endoscopy and/or manometry if necessary.