Management of distal oesophageal spasm
As distal oesophageal spasm may be precipitated or exacerbated by gastro-oesophageal reflux, a trial of proton pump inhibitor (PPI) therapy may produce substantial improvement and should be used as initial therapy. Suitable high-dose PPI regimens are1:
1esomeprazole 20 mg orally, twice daily, half to one hour before a meal esomeprazole esomeprazole esomeprazole
OR
1lansoprazole 30 mg orally, twice daily, half to one hour before a meal lansoprazole lansoprazole lansoprazole
OR
1omeprazole 20 mg orally, twice daily, half to one hour before a meal omeprazole omeprazole omeprazole
OR
1pantoprazole 40 mg orally, twice daily, half to one hour before a meal pantoprazole pantoprazole pantoprazole
OR
1rabeprazole 20 mg orally, twice daily, half to one hour before a meal. rabeprazole rabeprazole rabeprazole
If symptoms respond to 4 to 8 weeks of PPI therapy, maintenance and step-down therapy is as for Maintenance and step-down therapy for GORD in adults. To determine the degree of improvement on acid suppression, periods of symptom monitoring (both on and off PPI therapy) may be required.
Sipping warm water at the onset of an episode of distal oesophageal spasm may be beneficial. If this is not effective, sublingual nitrates may shorten the episodeEyre, 2011; use:
glyceryl trinitrate spray 400 micrograms sublingually, as required glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate
OR
glyceryl trinitrate tablet 600 micrograms sublingually, as required. glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate
If episodes of distal oesophageal spasm are frequent and disabling, consider a trial of one of the followingKhalaf, 2018:
1diltiazem modified-release 180 mg orally, daily, increasing to 240 or 360 mg orally, daily depending on response and adverse effects diltiazem diltiazem diltiazem
OR
1isosorbide dinitrate 10 to 20 mg orally, 3 to 4 times daily isosorbide dinitrate isosorbide dinitrate isosorbide dinitrate
OR
1nifedipine modified-release 30 mg orally, daily, increasing to 60 mg orally, daily depending on response and adverse effects. nifedipine nifedipine nifedipine
The dose required to improve symptoms may be associated with significant hypotension, especially in elderly patients—monitor these patients closely because there is an increased risk of falls. For patients already taking an antihypertensive drug, consider switching to one of the drugs above.
Consider referral to a gastroenterologist for patients with refractory symptoms or frequent disabling episodes.
Although evidence is limited, refractory symptoms have been treated by injecting botulinum toxin type A into the lower oesophageal sphincter, or myotomy of the lower oesophagus. Other potential therapies include phosphodiesterase inhibitors or neuromodulator therapy (eg tricyclic antidepressant, selective serotonin reuptake inhibitor), cognitive behavioural therapy or other chronic pain management strategies.