What To Know About Esophageal Spasms

An esophageal spasm occurs when the esophageal muscles contract abnormally. (These muscles are located in the esophagus, the tube that carries food to the stomach.)

Often triggered by eating, these muscle spasms affect digestion, causing chest pains and other symptoms. This can be an acute (temporary) issue or a chronic, persistent disorder.

Also known as nutcracker esophagus or distal or diffuse esophageal spasm (DES), esophageal spasm is a rare disorder affecting about 1 in 100,000 people. It isn't a life-threatening health issue, but it can cause severe discomfort and impact your quality of life.

Determining the cause of esophageal spasms is critical for managing it. This starts by understanding what esophageal spasm feels like, what can set it off, and when you should get help.

Symptoms

Esophageal spasm symptoms can resemble those of a heart attack, causing painful muscle contractions in the chest and upper abdomen. The pain is retrosternal (behind the breastbone) and feels crushing, squeezing, or sharp. It begins in the chest and can move to the back.

Dysphagia (difficulty swallowing) is another sign of esophageal spasm. It may feel like an object is blocking your throat or chest when there's nothing there—a feeling called globus hystericus.

In what's sometimes termed diffuse or distal esophageal spasm, there may also be a backflow of stomach acids or undigested foods. Known as regurgitation, this can lead to vomiting and heartburn, a burning sensation in the chest. When chronic and severe, additional symptoms may include voice hoarseness and cough.

Esophageal spasms can be episodic, though some have persistent, chronic episodes. The symptoms come and go, with attacks lasting a few minutes to one hour or more. Symptoms often develop shortly after eating or drinking hot or cold items but can happen anytime. Because eating becomes difficult, chronic cases can cause unintended weight loss.

Causes of Esophageal Spasm

Researchers do not fully understand the causes of esophageal spasms. The current theories link the condition to irregular nerve activity in the esophageal muscles, exposure to stomach acids due to gastroesophageal reflux disease (GERD), and motor problems with the esophagus.

Altered Nerve Activity

During normal swallowing, the esophageal muscles make coordinated contractions, pushing food or drink into the stomach. This process takes 2-4 seconds for liquids and about eight seconds for solids. These contractions occur automatically and are regulated by nerves, which work to activate and relax the esophageal muscles as needed. 

Esophageal spasms occur when these nerves misfire and don't work together. This causes a mismatch between the excitatory signals telling muscles to contract and the inhibitory ones, which relax them. The chemical nitrous oxide plays a role in this process, with insufficient levels thought to spur these muscle spasms.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) occurs due to dysfunction in the lower esophageal sphincter—the valve between the esophagus and stomach. As a result, stomach acids flow back up, causing chronic symptoms, including:

• Heartburn
• Chest pains
• Nausea
• Vomiting
• Swallowing difficulties (dysphagia)
• Chronic cough
• Hoarse voice

Some researchers believe this constant exposure to stomach acids affects the esophageal muscle nerves, causing their patterns of activity to change and leading to esophageal spasms. Many people who have esophageal spasms have GERD. 

Spastic Achalasia

Another potential cause of esophageal spasm is spastic achalasia, a rare motility disorder (trouble moving food through the body).

With spastic achalasia, your esophageal muscles don't contract while swallowing. The lower esophageal sphincter fails to relax, making swallowing solids or liquids impossible. Often mistaken for GERD, common signs of spastic achalasia include:

• Heartburn
• Dysphagia
• Regurgitation, the backflow of stomach acids in the esophagus
• Chest pains
• Night-time cough
• Wheezing while eating
• Weight loss
• Noisy or labored breathing

Researchers believe inhibition of nitrous oxide could be the trigger for both esophageal spasm and spastic achalasia. There are cases of the former developing into severe forms of the latter.

Triggers

While there's still debate about the exact causes of esophageal spasms, researchers have identified potential triggers. This issue can occur independently of eating or drinking, but for many, attacks start after consuming very hot or cold foods.

Other reported triggers include high-fat foods, spicy foods, and caffeinated beverages.

Risk Factors

All people can develop esophageal spasms, but this issue is more common among certain populations. The disease affects older populations, with an average onset of 60. This condition is also more prevalent among people assigned female at birth.

When To See a Healthcare Provider

You should contact a healthcare provider if you have multiple attacks of esophageal spasm symptoms or have been experiencing them for two weeks or more. Because sharp chest pains could also mean a heart attack, get emergency help if you have them longer than five minutes.

Healthcare providers will need to rule out heart attack or heart-related causes. To do this, they may monitor your heart using an electrocardiogram (EKG), angiogram, or other imaging and clinical tests.

Your primary care provider may refer you to a gastroenterologist—a digestive health specialist—for diagnosis and treatment. Tests that diagnose this condition include:

• Endoscopy: Healthcare providers pass a flexible tube with a camera down the esophagus to screen for physical obstructions or other issues.
• Barium swallow: After swallowing barium, a radioactive compound, healthcare providers take an X-ray. Narrowed parts of the esophagus become more visible in imaging.
• Esophageal manometry: Healthcare providers place a catheter with sensors in the esophagus to track the muscle movements when you swallow.

Treatments for Esophageal Spasm

The goal of treatment for esophageal spasms is to stop the irregular activity of the esophageal muscles. The symptoms ease when the muscles relax.

The specific course of treatment depends on the severity and the individual case, with options ranging from home remedies to surgeries.

Home Remedies

Research suggests that peppermint oil may help relieve minor symptoms. In one study of people with chest pain and trouble swallowing, 63% reported at least some symptom improvement with this supplement.

Another common method involves adding a few drops of peppermint oil into water and drinking it.

Medications

Medications for esophageal spasms either work to ease symptoms in intermittent cases or prevent attacks in chronic ones. These may include:

• Proton pump inhibitors (PPIs): Drugs like Prilosec (omeprazole) and Prevacid (lansoprazole) ease reflux, heartburn, and other symptoms.
• Nitrates: Sun-dermal nitroglycerin is applied under the tongue to relieve attacks. Isordil (isosorbide dinitrate) is taken before meals to prevent attacks.
• Calcium-channel inhibitors: A type of blood pressure medication, calcium-channel inhibitors like Cardizem (diltiazem) relax esophageal muscles, stopping attacks and easing pain.
• Tricyclic antidepressants: Tricyclic antidepressants like Tofranil (imipramine) act on the nerves of the esophageal muscles to stop pain and ease symptoms.
• Botox injection: Botulinum toxin A (Botox) injections put esophageal nerves to "sleep," temporarily stopping spasms. Considered for more severe or chronic cases, the effects of each treatment last about one year.

Surgery

In very severe and difficult-to-treat cases of esophageal spasm, a gastroenterologist may consider myotomy surgery.

Peroral endoscopic myotomy (POEM) is a common approach. Surgeons use minimally invasive techniques to cut the lower esophageal muscle, stopping spasms and allowing food to reach the stomach with the force of gravity.

Prevention

Because the causes are unclear, there's no way to prevent esophageal spasms in some cases. If your symptoms occur after eating, determine what may be triggering the attacks and work to avoid them. These can include:

• Cold foods, like ice cream or popsicles
• Hot liquids, such as hot tea or broth
• Spicy foods
• Fatty foods, such as red meat or bacon
• Caffeinated drinks, such as coffee, black or green tea, and certain sodas

If you're prone to attacks, it may also help to keep a journal. Track your symptoms, foods triggering attacks, and any medications you're taking. Not only will you better understand your condition, but you'll have helpful information for your healthcare provider.

A Quick Review

An esophageal spasm occurs when the muscles of the esophagus contract uncontrollably, causing severe chest pains, difficult or painful swallowing, heartburn, and other symptoms. These spasms are rare and may only happen intermittently.

Though this condition can resemble a heart attack, it's not dangerous or fatal. Researchers aren't sure of the causes but have linked it to abnormal nerve activity among the esophageal muscles.

Medications can help both treat and prevent this condition, with surgery reserved for very severe cases.