A man with progressive dysphagia
TREATMENTS FOR ESOPHAGEAL SPASM
In addition to incorporating data obtained from endoscopy, esophagography, and manometry, it is crucial to identify the patient’s predominant symptom when planning treatment. For example, is the prevailing symptom dysphagia or chest pain? Additional consideration must be given to medical, surgical, and psychiatric comorbidities.
5. Which of the following is appropriate medical therapy for esophageal spasm?
- Calcium channel blockers
- Nitrates
- Hydralazine
- Phosphodiesterase 5 (PDE5) inhibitors
- All of the above
All of these have been used to treat distal esophageal spasm as well as other hypercontractile esophageal motility disorders.8–20
Calcium channel blockers have proven to be effective in randomized controlled trials. Diltiazem has been shown to be beneficial at doses ranging from 60 to 90 mg, as has nifedipine 10 to 20 mg 3 times daily. Although different drugs of this class tend to relax the lower esophageal sphincter to different degrees, when choosing among them in patients with hypercontractile disorders there is little concern for potentially precipitating reflux.8–13
Nitrates, hydralazine, and PDE5 inhibitors have been effective in uncontrolled studies but have not been studied in randomized trials.14–17
Other treatments. Patients may also benefit from neuromodulators such as trazodone and imipramine for chest pain and optimization of antisecretory therapy if they have concomitant gastroesophageal reflux disease.18–20
Patients who have documented esophageal hypercontractility along with reflux disease confirmed by an abnormal pH study show significant improvement in their chest pain symptoms with high doses of a proton pump inhibitor (PPI). As our patient presented with chest pain and dysphagia, a dedicated pH study was not needed, and we could progress straight to manometry and a trial of a PPI.
Our patient was started on a PPI and nifedipine but developed a pruritic rash. As rash does not preclude using another medication in the same class, his treatment was changed to diltiazem 30 mg by mouth 3 times a day, and his dysphagia improved. However, he continued to experience intermittent chest pain with swallowing. After discussion of neuromodulator therapy, he declined additional pharmacologic therapy.
A NONPHARMACOLOGIC TREATMENT?
6. Which of the following would you offer this patient as a nonpharmacologic alternative for his esophageal pain?
- St. John’s wort
- Ginkgo biloba
- Ginseng
- Peppermint extract
- Eucalyptus oil
In a small, open-label study in patients with esophageal spasm, the use of 5 drops of commercially available 11% peppermint extract in 10 mL of water significantly decreased simultaneous contractions and resolved chest pain.21 Esophageal manometry was performed 10 minutes after the peppermint solution was consumed, and the results showed improvement in esophageal spasm. While the authors of this study did not make any formal recommendations, the findings suggest that peppermint extract should be given 10 minutes before meals.
There is no evidence for or against the use of the other nonpharmacologic treatments mentioned here.
PAIN RELIEF
7. If a pharmacologic approach were chosen, which would be the best option for pain relief in this patient?
- Oxycodone 5 mg every 8 hours
- Acetaminophen 650 mg every 8 hours
- Ibuprofen 400 mg every evening at bedtime
- Trazodone 100 mg every evening at bedtime
- Imipramine 50 mg every evening at bedtime
- Aripiprazole 5 mg by mouth every day
Trazodone would be the most appropriate of these options. Doses of 100 mg to 150 mg every evening at bedtime have been shown to significantly improve global assessment scores of pain at 6 weeks.18
Imipramine 50 mg every evening at bedtime would be another option and also has been shown to reduce chest pain.19
Even though these were the doses that were investigated, in clinical practice it is common to start at lower doses (trazodone 50 mg or imipramine 10 mg) and to then titrate every 4 weeks based on the patient’s response.
Opiates (eg, oxycodone) should be avoided, as they can cause esophageal motility disorders such as spasm or achalasia.22
Acetaminophen and aripiprazole have not been studied exclusively for their effect on chest pain related to esophageal spasm.
RECURRENT SYMPTOMS
The patient’s dysphagia initially decreased while he was taking diltiazem 30 mg 3 times a day, but it recurred after 6 months. The dosage was increased to 60 mg 3 times a day over the course of the next year, with minimal response. (The maximum dose is 90 mg 4 times a day, but because of side effects of lightheadedness and dizziness, out patient could not tolerate more than 60 mg 3 times a day).
