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Esophageal spasm 201
Calcium channel blockers decrease the amplitude and duration of esopha-
geal spasms, but their use does not consistently result in better analgesia than
achieved with placebo. 6 There are relatively few studies, and all of the trials
are limited by low numbers. The agents that have been assessed for utility in
esophageal spasm are nifedipine, verapamil, and diltiazem. Two studies,
conducted in patients with nutcracker esophagus, found that diltiazem
(administered in a variety of regimens ranging upwards from 90 mg QID)
decreased mean chest pain scores. 6,7 A small uncontrolled trial found that
nifedipine (10 mg PO) reduced esophageal pain acutely. 8 Other studies,
following patients for more extended periods of time, showed little or no
clinical benefit. 5,8 Inconsisent calcium channel blocker pain relief for esophageal
spasm is probably related to the absence of correlation between reduction
of esophageal contraction amplitude and pain improvement. 9
Anticholinergic agents such as atropine (6–12 μg/kg IV), hyoscyamine
(0.6mg PO), or propantheline bromide (30 mg PO) decrease peristaltic contractions
and reduce esophageal sphincter tone. 5,10 Despite these promising
physiologic findings, and the frequent mention of anticholinergic agents as
potentially useful in the treatment of esophageal motility disorders, there
have been no clinical trials of drugs in this class for esophageal spasm pain. 5,9
Given the absence of supporting evidence for analgesia, and the known
unreliability of esophageal muscular tone as an indicator of clinical pain
relief in esophageal spasm, anticholinergics cannot be recommended for
routine use in acute treatment of esophageal spasm pain.
There is evidence supporting the use of antidepressants such as tricyclics,
trazodone, and SSRIs for treating chest pain caused by esophageal spasm. 5,9
Compared with the relatively new SSRI agents, tricyclic drugs and trazodone
(which has a slightly more favorable safety profile) are more extensively
studied for esophageal spasm pain. Early data show sertraline decreases
frequency of chest pain episodes. 11,12 The tricyclic drugs seem to work somewhat
better than trazodone; useful ones include amitripyline, nortriptyline,
imipramine, and desipramine. 9,13
The mechanism by which antidepressants relieve chest pain of esophageal
origin is poorly understood. One theory, based on the idea that pain is
caused more by hyperalgesia than spasm itself, is that antidepressants work