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Esophageal spasm
KALANI OLMSTED AND DEBORAH B. DIERCKS
n Agents
n Proton pump inhibitors
n Nitrates
n Anticholinergic agents
n Calcium channel blockers
n Antidepressants: tricyclics, trazadone, SSRIs
n Evidence
Proton pump inhibitors (PPIs) are recommended as a first-line therapy
when chest pain is thought to be caused by esophageal spasm. This is
because gastroesophageal reflux (GERD) causes similar symptoms, and
GERD is much more common than esophageal spasm. 1 The diagnosis is
complicated by the complexity of esophageal pain pathways. Central convergence
of pain blurs the distinction between reflux pain and discomfort
from esophageal spasm (as well as other disorders). 1,2 The case for early use
of PPIs in suspected esophageal spasm is strengthened by the fact that acid
reflux can actually cause spasm. 1
Both long- and short-acting nitrates have been shown to provide
some relief of pain caused by esophageal spasm. 3,4 In the ED treatment
of patients presenting with chest pain, it is reasonable to try sublingual
nitroglycerin (glyceryl trinitrate) early. Through its mechanism of smooth
muscle relaxation (at both vascular and esophageal sites) nitroglycerin can
potentially improve symptoms in cardiac chest pain, GERD, or esophageal
spasm. 3,5 There have, however, been only small studies (and no controlled
trials) of nitrates in patients with chest pain of esophageal origin. While
amplitude, frequency, and duration of esophageal contractions are
decreased with nitrates, clinical pain reduction seems to be inconsistent
and unpredictable. 1,5