What Is Esophageal Spasm?
Esophageal spasm is an esophageal motility disorder characterized by simultaneous, uncoordinated, high-amplitude contractions of the smooth musculature of the esophagus. It manifests clinically as retrosternal chest pain and/or difficulty swallowing (dysphagia).
There are two main forms: distal esophageal spasm (DES), formerly called diffuse esophageal spasm, and the jackhammer esophagus, characterized by extremely high-amplitude contractions. Both are diagnosed by high-resolution manometry.
It is a relatively rare condition, responsible for less than 5% of cases of noncardiac chest pain. However, it has significant clinical importance because the chest pain can be indistinguishable from angina, generating anxiety and repeated cardiology investigations.
Abnormal Contractions
The esophagus contracts simultaneously (instead of sequential peristaltic) or with excessive amplitude, preventing adequate transit of the food bolus.
Mimics Angina
The chest pain of esophageal spasm can be identical to cardiac angina, including radiation to the arm and jaw and relief with nitroglycerin.
Rare Condition
Responsible for less than 5% of cases of noncardiac chest pain. Diagnosis requires high-resolution esophageal manometry.
Pathophysiology
Normal esophageal peristalsis is a sequential contraction wave that propels the food bolus from the pharynx to the stomach, controlled by inhibitory (nitric oxide) and excitatory (acetylcholine) neurons of the myenteric plexus. In esophageal spasm, there is dysfunction of the inhibitory neurons, resulting in loss of the orderly peristaltic sequence.
Reduction of nitric oxide (NO) in the myenteric plexus removes the coordinated inhibition that precedes the peristaltic wave, allowing simultaneous or premature contractions of the circular musculature. In jackhammer esophagus, contraction amplitude is extremely high (more than 8,000 mmHg.cm.s in the distal contractile integral).
Clinical Associations
Esophageal spasm is frequently associated with gastroesophageal reflux disease — acid exposure can trigger reflex spasms of the esophageal musculature. There is also association with anxiety, stress, and ingestion of very hot or cold foods or liquids.
Some patients with esophageal spasm may evolve to achalasia over time, suggesting that esophageal motility disorders may represent a spectrum of progressive loss of inhibitory neurons.
Symptoms
The two cardinal symptoms are retrosternal chest pain and dysphagia. Pain can occur spontaneously or be triggered by swallowing. It is frequently episodic and unpredictable.
Symptoms of Esophageal Spasm
- 01
Retrosternal chest pain
Intense squeezing or pressing pain that can radiate to the back, jaw, and arms. Can be indistinguishable from cardiac angina.
- 02
Dysphagia for solids and liquids
Difficulty swallowing both solids and liquids, different from mechanical dysphagia which is progressive and predominates for solids.
- 03
Odynophagia
Pain on swallowing, especially with very hot, cold, or carbonated foods.
- 04
Regurgitation
Return of food to the esophagus or mouth during spasm episodes.
- 05
Episodic symptoms
Symptoms are intermittent and unpredictable, alternating with asymptomatic periods. Can be triggered by stress.
- 06
Sensation of esophageal lump
Sensation of food "stuck" in the chest during spasm episodes.
Diagnosis
Definitive diagnosis requires high-resolution esophageal manometry (HRM), which allows precise characterization of the motor pattern. Upper digestive endoscopy is important for ruling out mechanical causes of dysphagia (stricture, ring, neoplasia).
Cardiology evaluation (electrocardiogram, stress test, eventually catheterization) should precede esophageal investigation in patients with chest pain, especially in the presence of cardiovascular risk factors.
🏥Diagnostic Criteria (Chicago Classification v4.0)
- 1.Distal esophageal spasm: more than 20% of premature contractions (DL less than 4.5 seconds) with intermittent normal peristalsis
- 2.Jackhammer esophagus: DCI greater than 8,000 mmHg.cm.s in at least 20% of swallows
- 3.Absence of mechanical obstruction to esophagogastric flow
- 4.Compatible clinical symptoms (chest pain and/or dysphagia)
- 5.Exclusion of cardiac disease in patients with predominant chest pain
DIAGNÓSTICO DIFERENCIAL
Diagnóstico Diferencial
Achalasia
- Progressive dysphagia for solids and liquids
- Regurgitation of undigested food
- No chest pain
Testes Diagnósticos
- Esophageal manometry
- Esophagogram
GERD
Leia mais →- Predominant heartburn
- Improvement with PPIs
- Endoscopy with esophagitis
Testes Diagnósticos
- Endoscopy
- pH monitoring
Cardiac Chest Pain
- Radiation to arm/jaw
- Cardiovascular risk factors
- Worsens with exertion
- Chest pain = rule out MI before treating esophagus
Testes Diagnósticos
- ECG
- Troponin
Eosinophilic Esophagitis
- Food bolus impaction
- Dysphagia in young people with atopy
- Eosinophilia on biopsy
Testes Diagnósticos
- Endoscopy with biopsy
Candida Esophagitis
- Odynophagia
- Immunosuppressed or inhaled corticosteroid use
- White plaques on endoscopy
Testes Diagnósticos
- Endoscopy
Cardiac Chest Pain: The Exclusion That Comes First
Chest pain of esophageal origin and cardiac pain are clinically indistinguishable without complementary investigation — both can have a retrosternal burning or squeezing character, with radiation to arms and jaw, and even improvement with nitrates (which relax both cardiac and esophageal muscle). For this reason, cardiac evaluation is always the first step: ECG, troponin, and assessment of cardiovascular risk factors are mandatory before any esophageal investigation.
Studies show that 10-30% of patients with noncardiac chest pain have esophageal spasm as an identifiable cause. The diagnosis of "chest pain of esophageal origin" is one of exclusion — it can only be safely confirmed after normal cardiology evaluation. High-resolution esophageal manometry and pH monitoring with impedance are the definitive tests for characterizing the responsible esophageal motor disorder.
Achalasia vs Esophageal Spasm: Motor Disorders with Distinct Presentations
Achalasia is the most important esophageal motor disorder in differential diagnosis. Unlike esophageal spasm — which causes episodic chest pain generally preserving swallowing — achalasia causes progressive and inexorable dysphagia for solids and liquids, with regurgitation of undigested (non-acidic) food. Weight loss is frequent in advanced stages. High-resolution esophageal manometry is the gold standard: in achalasia, it shows absence of peristalsis and non-relaxation of the lower esophageal sphincter.
The barium esophagogram shows the "bird's beak" appearance in achalasia — abrupt narrowing at the esophagogastric junction with dilation of the esophageal body above. In spasm, the esophagogram may show simultaneous contractions in a "corkscrew" pattern. The distinction is essential because treatments are radically different: achalasia requires Heller myotomy, pneumatic dilation, or POEM; spasm responds to calcium channel blockers, antidepressants, and acupuncture.
Eosinophilic Esophagitis and Candida Esophagitis: Treatable Causes of Esophageal Dysfunction
Eosinophilic esophagitis (EoE) is an allergic inflammatory condition that should be considered in young adults with episodic dysphagia for solids and a history of atopy (asthma, rhinitis, eczema). Food bolus impaction — when food stops completely in the esophagus — is a dramatic and characteristic presentation. Endoscopy shows esophageal rings ("trachealization"), longitudinal furrows, and whitish plaques; biopsy confirms with more than 15 eosinophils per high-power field. It does not respond to PPIs — treatment with topical corticosteroids and elimination diet.
Candida esophagitis causes odynophagia (pain on swallowing) in immunosuppressed patients — HIV/AIDS, transplant recipients, those on inhaled corticosteroids (without post-use oral hygiene), chemotherapy, or prolonged PPI use. Adherent white plaques on the esophageal mucosa on endoscopy are the classic presentation. Systemic antifungal treatment (fluconazole) is highly effective. The distinction from esophageal spasm is relatively simple by clinical context and endoscopic findings.
Treatment
Treatment of esophageal spasm is stepwise, starting with treatment of associated reflux (PPI), followed by smooth muscle relaxants and, in refractory cases, neuromodulators or interventional procedures.
Standard-dose PPI is the first step, since coexisting reflux can trigger or aggravate spasms. Nitrates (isosorbide dinitrate) and calcium channel blockers (nifedipine, diltiazem) relax esophageal smooth muscle and may relieve pain and dysphagia.
Tricyclic antidepressants (imipramine, amitriptyline) at low doses are effective as visceral neuromodulators, reducing esophageal hypersensitivity and pain perception. Botulinum toxin injection in the esophagus and peroral endoscopic myotomy (POEM) are options for refractory cases.
First Line: PPI and Behavioral
Double-dose PPI for 8 weeks to treat associated reflux. Avoid triggers (very hot/cold foods, stress). Anxiety management.
Smooth Muscle Relaxants
Nifedipine 10-30 mg before meals or sublingual isosorbide dinitrate for crises. Side effects: hypotension, headache.
Neuromodulators
Amitriptyline or imipramine 25-50 mg at night. Reduce esophageal hypersensitivity and the frequency of painful episodes.
Endoscopic Interventions
Botulinum toxin injection (temporary effect, 3-6 months) or POEM (peroral endoscopic myotomy) for severe refractory cases.
Acupuncture as Treatment
Acupuncture can be considered as complementary therapy for esophageal spasm, with proposed mechanisms including modulation of the autonomic nervous system, possible relaxation of visceral smooth muscle, reduction of esophageal hypersensitivity, and modulation of descending pain inhibitory pathways.
Experimental studies show that acupuncture can modulate esophageal motility and reduce lower esophageal sphincter tone. Reduction of anxiety and stress — known triggering factors — is a relevant additional benefit.
Although specific evidence for esophageal spasm is limited, acupuncture may be useful as part of a multimodal approach, especially in patients with significant anxious component or who do not tolerate conventional pharmacotherapy.
Prognosis
Esophageal spasm is a benign condition with a fluctuating course. Most patients have intermittent episodes that do not significantly compromise nutritional status. Chest pain is frequently the most impactful aspect on quality of life.
About 20% of patients may evolve to achalasia over years, especially those with progressive impairment of LES relaxation. Follow-up with periodic manometry is indicated in cases with progressive dysphagia.
With adequate treatment — combining PPI, neuromodulators, and anxiety management — most patients achieve satisfactory symptom control and maintain good quality of life.
Myths and Facts
Myth vs. Fact
Chest pain always means a heart problem
The esophagus and heart share the same sensory innervation, making the pain clinically indistinguishable. Up to 30% of chest pain investigated in emergencies has esophageal cause, not cardiac.
Esophageal spasm is caused by emotional stress
Although stress can trigger episodes, esophageal spasm has a neurogenic basis — dysfunction of inhibitory neurons of the myenteric plexus. It is a motor disorder, not psychosomatic.
Nitroglycerin only works for cardiac pain
Nitroglycerin relaxes all smooth muscle, including esophageal. Therefore, pain relief with nitroglycerin does not confirm a cardiac cause — it may be esophageal spasm.
Esophageal spasm always evolves to achalasia
Only about 20% of patients evolve to achalasia. Most maintain the picture of intermittent spasm over the years, with response to clinical treatment.
When to Seek Help
Chest pain should always be evaluated, especially in the presence of cardiovascular risk factors. After ruling out cardiac cause, esophageal investigation is the next step.
Frequently Asked Questions about Esophageal Spasm
Esophageal spasm is a motor disorder of the esophagus characterized by disorganized, high-pressure, or simultaneous esophageal muscle contractions (instead of coordinated peristaltic ones). It manifests mainly as intense and episodic retrosternal chest pain — frequently confused with angina — and/or intermittent dysphagia. Episodes can last minutes to hours, occur spontaneously or be triggered by hot or cold foods, stress, or underlying GERD. There is no "visible spasm" — diagnosis is made by esophageal manometry.
Clinical differentiation is impossible without tests — pain can be identical in both conditions: retrosternal, burning or pressing, with radiation to the arms. Therefore, every patient with intense chest pain should be evaluated with ECG and troponin to rule out acute coronary syndrome. Features that suggest spasm (but do not confirm): pain that improves with nitrates or antacids, relationship with swallowing of specific foods, absence of cardiovascular risk factors, and recurrent episodes with documented normal cardiac evaluation.
High-resolution esophageal manometry (HRM) is the gold standard for diagnosis of esophageal motor disorders. In distal esophageal spasm (DES), it shows simultaneous (non-peristaltic) contractions in at least 20% of swallows, with normal distal integrated pressure. In jackhammer (hypercontractile) esophagus, it shows very high-amplitude contractions. Barium esophagogram can show suggestive findings ("corkscrew"), but is less sensitive than manometry. Endoscopy is performed to rule out structural causes.
Yes. Acid exposure of the esophagus from GERD can sensitize esophageal neurons and trigger spasmodic contractions — GERD is one of the most common triggers of spasm. For this reason, treatment with PPIs is frequently the first therapeutic approach: if spasms improve with PPI, this confirms the role of acid as a trigger. pH monitoring with impedance documents reflux and guides the intensity of antisecretory treatment needed.
Common triggers include: very cold or very hot drinks (amplify the esophageal motor response); acidic foods and carbonated drinks (especially in patients with underlying GERD); rapid meals without adequate chewing; acute stress and anxiety (the brain-esophagus axis is bidirectional); and some medications such as prokinetics. Keeping an episode diary identifying personal triggers is a practical strategy to reduce spasm frequency.
Acupuncture can be considered as complementary therapy. Specific evidence for esophageal spasm is limited to case reports and small series, but proposed mechanisms — reduction of visceral sensitization, modulation of autonomic tone, anxiolytic effect, and possible smooth muscle relaxation — support its use as adjuvant in selected patients, especially with significant anxious component. It does not replace PPI, calcium channel blockers, or neuromodulators in cases with pharmacological indication. Treatment is conducted by a medical acupuncturist in cycles of 10-12 sessions.
Yes, with moderate evidence. Calcium channel blockers such as diltiazem and nifedipine relax esophageal smooth muscle, reducing contraction amplitude. Studies show benefit in 60-70% of patients with symptomatic esophageal spasm. Side effects (hypotension, lower-limb edema, headache) limit tolerability in some patients. Low doses are generally used — diltiazem 60-90 mg 3x/day or nifedipine 10-30 mg/day. The physician will adjust the dose based on response and tolerability.
Yes, in some cases. Distal esophageal spasm can cause intermittent dysphagia — especially for solids — due to uncoordinated contractions that prevent normal transport of the food bolus. Different from achalasia (progressive and constant dysphagia), in spasm dysphagia the episodes are intermittent and may vary in intensity. Sensation of food "stuck" in the chest may occur. Dysphagia that progressively worsens requires urgent endoscopic and manometric investigation to rule out achalasia and esophageal stenosis.
Yes, in neuromodulatory doses (lower than antidepressant doses). Tricyclic antidepressants such as imipramine and amitriptyline (25-50 mg/day) and SSRIs reduce esophageal visceral hypersensitivity — the central mechanism of pain amplification in spasm. Trazodone (100-150 mg/day) also has specific evidence for chest pain of esophageal origin. These medications act on neural "amplification" of pain, not directly on muscle. Cognitive-behavioral psychotherapy can be complementary in patients with anxiety comorbidity.
Esophageal spasm is rarely an emergency, but requires urgent evaluation when: chest pain is intense and of sudden onset (rule out coronary syndrome); there is progressive dysphagia for liquids (suggests advanced achalasia); complete food impaction occurs (bolus retained in the esophagus — endoscopic emergency); there is significant associated weight loss; or if the patient has not tolerated any medication and has frequent disabling episodes. In this last case, botulinum toxin injection in the sphincter or pneumatic dilation are advanced therapeutic options.
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