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Esophageal Spasms: Primary Motility Disorders and Secondary Causes

What Are Esophageal Spasms?

Esophageal spasms are uncoordinated, often painful contractions of the esophageal smooth muscle that disrupt normal peristalsis. They can cause chest pain, dysphagia, and regurgitation.

Primary Esophageal Motility Disorders Causing Spasms

DisorderKey FeaturesManometry Findings (Chicago Classification v4.0)
AchalasiaImpaired LES relaxation + absent peristalsis; dysphagia to solids/liquids, regurgitation, weight lossType I: minimal contractility; Type II: panesophageal pressurization; Type III: spastic (premature) contractions
Distal Esophageal Spasm (DES)Intermittent dysphagia, chest pain; normal LES relaxation≥20% premature contractions (DL <4.5 s) with normal LES relaxation
Jackhammer EsophagusSevere chest pain, dysphagia; high‑amplitude contractions≥20% swallows with DCI >8000 mmHg·s·cm (hypercontractile)
Eosinophilic Esophagitis (EoE)Dysphagia, food impaction, reflux‑like symptoms; atopic historyNon‑specific motility changes; diagnosis by biopsy (≥15 eos/hpf)
GERD‑related spasmReflux‑induced esophageal hyperalgesia and dysmotilityMay show ineffective esophageal motility (IEM) or fragmented peristalsis

Secondary Causes

  • Medications (opioids, anticholinergics, calcium channel blockers).
  • Systemic sclerosis (scleroderma) — absent peristalsis, low LES pressure.
  • Diabetic autonomic neuropathy.
  • Chagas disease (Trypanosoma cruzi).
  • Post‑fundoplication (gas‑bloat, dysmotility).

Diagnostic Approach

  1. History: chest pain vs. dysphagia pattern, triggers, regurgitation.
  2. Upper endoscopy: rule out structural lesions, eosinophilic esophagitis, Barrett's.
  3. High‑resolution manometry (HRM): gold standard for motility classification.
  4. Timed barium esophagram: functional assessment of emptying.
  5. pH‑impedance monitoring: if GERD suspected.

Treatment Overview

  • Achalasia: Pneumatic dilation, Heller myotomy (laparoscopic/robotic), POEM, botulinum toxin (temporary).
  • DES/Jackhammer: Smooth muscle relaxants (nitrates, CCBs), phosphodiesterase‑5 inhibitors, botulinum toxin injection, POEM (refractory).
  • EoE: PPI trial, topical steroids (budesonide/fluticasone), elimination diet, biologics (dupilumab).
  • GERD: PPI, lifestyle, fundoplication if refractory.

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