Oesophageal Spasm
Oesophageal Spasm Definition
- Oesophageal spasm is a motility disorder of the oesophagus characterised by abnormal, uncoordinated, or excessively strong contractions. These spasms can cause dysphagia (difficulty swallowing) and chest pain, which may mimic cardiac conditions. There are two primary types: diffuse oesophageal spasm (DES) and hypertensive peristalsis (nutcracker oesophagus).
Oesophageal Spasm Epidemiology, Risk Factors & Prevention
- Oesophageal Spasm Clinical Epidemiology
- Risk Factors: Gastro-oesophageal reflux disease (GORD), anxiety and stress, exposure to extreme temperatures in food or beverages, and certain neurological conditions affecting autonomic control are associated with an increased risk of oesophageal spasm. Some cases are idiopathic, while others may be linked to oesophageal hypersensitivity.
- Prevention: Avoiding dietary triggers such as very hot or cold drinks, managing acid reflux with lifestyle modifications and proton pump inhibitors, and reducing stress through relaxation techniques may help prevent or minimise symptoms. Early intervention in patients with GORD may reduce the likelihood of developing secondary oesophageal dysmotility.
Oesophageal Spasm Pathophysiology
- Oesophageal spasms occur due to abnormal functioning of the oesophageal smooth muscle or its innervation. The exact mechanism remains unclear, but it is thought to involve dysfunction in the myenteric plexus, resulting in uncoordinated or hypercontractile peristalsis. Gastro-oesophageal reflux disease (GORD) and other inflammatory processes may contribute to this dysfunction. Spasms result in either ineffective propagation of oesophageal content or hyperactivity of muscle contractions, causing chest pain or dysphagia.
Oesophageal Spasm Time Course
- Oesophageal spasms can present acutely or chronically, with episodic flare-ups of dysphagia or chest pain. Symptoms may last seconds to minutes during an acute episode. Over time, recurrent spasms can lead to chronic discomfort, with exacerbations related to triggers such as food, stress, or temperature extremes.
Oesophageal Spasm Symptoms
- Chest pain – Intermittent retrosternal pain resembling angina, often described as squeezing or tightness. This results from strong, uncoordinated oesophageal muscle contractions.
- Dysphagia – Difficulty swallowing due to the uncoordinated or abnormal peristalsis of the oesophageal muscles.
- Regurgitation – The return of food or liquids into the mouth, especially during a spasm episode due to ineffective clearance of food from the oesophagus.
Oesophageal Spasm Signs
- Normal physical examination – There are typically no abnormal findings on physical exam, as oesophageal spasm is an internal functional disorder. Diagnosis relies heavily on symptom history and diagnostic tests.
Oesophageal Spasm Red Flag Features
- Severe, persistent chest pain – Can mimic myocardial infarction; warrants immediate exclusion of cardiac causes.
- Unintentional weight loss – May suggest a more sinister pathology like oesophageal cancer or motility disorders.
- Haematemesis – Vomiting blood, which could indicate oesophageal rupture (Boerhaave syndrome) or severe GORD.
Oesophageal Spasm Atypical Presentations
- Some patients may present with vague, non-specific symptoms such as globus sensation (a feeling of a lump in the throat), or episodes of mild discomfort without overt dysphagia. This is thought to arise from mild, intermittent spasms without full obstruction of oesophageal content.
Oesophageal Spasm Diagnostic Tests
- Barium swallow – May show a corkscrew or rosary bead appearance of the oesophagus during spasm episodes.
- Oesophageal manometry – Reveals abnormal motility patterns such as simultaneous contractions or high-amplitude peristalsis, which are characteristic of oesophageal spasms.
- Endoscopy – Usually normal but performed to rule out structural causes of dysphagia or chest pain, such as strictures or malignancy.
Oesophageal Spasm Problem Representation
- A 55-year-old woman presents with intermittent episodes of retrosternal chest pain and difficulty swallowing, often triggered by cold liquids. Symptoms have been ongoing for several months, with recent worsening.
Oesophageal Spasm Differential Diagnosis
- Gastro-oesophageal reflux disease (GORD) – GORD often causes chest pain and dysphagia, but is associated with heartburn and regurgitation. It lacks the intermittent, spastic nature of oesophageal spasm.
- Achalasia – A motility disorder characterised by failure of the lower oesophageal sphincter to relax, leading to progressive dysphagia for solids and liquids, typically without the severe pain of oesophageal spasms.
- Myocardial infarction (MI) – Must be excluded as chest pain is a common feature. Unlike oesophageal spasm, MI-related pain is not related to swallowing or eating.
Oesophageal Spasm Treatment
- Calcium channel blockers (e.g. nifedipine) – These relax smooth muscle and are often used to reduce the intensity and frequency of spasms.
- Botulinum toxin injection – Can be used in refractory cases to inhibit acetylcholine release, reducing oesophageal contractions.
- Proton pump inhibitors (PPIs) – Used if gastro-oesophageal reflux is a contributing factor.