Esophageal spasm

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

• Strong spasms of the musculature of the esophagus that can last minutes to hours and mimic the chest pain of angina
• Unclear what causes esophageal spasm. Possibly related to food intolerance.

Clinical Features

• Squeezing or tightening pain in the chest
• Can have associated dysphagia +/- globus sensation
• Can be triggered by eating hot or cold drinks/food.

Differential Diagnosis

Chest pain

Critical

• Acute coronary syndromes (ACS)
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic dissection
• Cardiac tamponade
• Coronary artery dissection
• Esophageal perforation (Boerhhaave's syndrome)
• Pulmonary embolism
• Tension pneumothorax

Emergent

• Cholecystitis
• Cocaine-associated chest pain
• Mediastinitis
• Myocardial rupture
• Myocarditis
• Pancreatitis
• Pericarditis
• Pneumothorax

Nonemergent

• Aortic stenosis
• Arthritis
• Asthma exacerbation
• Biliary colic
• Costochondritis
• Esophageal spasm
• Gastroesophageal reflux disease
• Herpes zoster / Postherpetic Neuralgia
• Hypertrophic cardiomyopathy
• Hyperventilation
• Mitral valve prolapse
• Panic attack
• Peptic ulcer disease
• Pleuritis
• Pneumomediastinum
• Pneumonia
• Rib fracture
• Stable angina
• Thoracic outlet syndrome
• Valvular heart disease
• Muscle sprain
• Psychologic / Somatic Chest Pain
• Spinal Root Compression
• Tumor

Evaluation

Workup

• Esophageal spasm is a diagnosis of exclusion. Work-up should focus on ruling out more serious etiologies.
  • ECG
  • CBC
  • Chemistry
  • Troponin
  • CXR
• Consider:
  • BNP
  • PT/PTT
  • D-dimer vs. CTA chest

Diagnosis

• Diagnosis of exclusion
• Upper gastrointestinal endoscopy with esophageal biopsies obtained to rule out other causes
• Followed by esophageal manometry

Management

• Step-wise approach to therapy is recommended

1. Pharmacologic therapy focused on controlling GERD symptoms
2. Trial of peppermint oil before meals
3. Trial of Calcium channel blockers
4. If the above are not successful consideration of Tricyclic antidepressants

Disposition

• Outpatient GI referral and work-up

See Also

• Chest pain
• Achalasia