Symptomatic distal esophageal spasm is part of a spectrum of motility disorders characterized variously by nonpropulsive contractions and hyperdynamic contractions, sometimes in conjunction with elevated lower esophageal sphincter pressure. Symptoms are chest pain and sometimes dysphagia. Diagnosis is by barium swallow or manometry. Treatment is difficult but includes nitrates, calcium channel blockers, botulinum toxin injection, surgical or endoscopic myotomy, and antireflux therapy.
Abnormalities in esophageal motility correlate poorly with patient symptoms; similar abnormalities may cause different or no symptoms in different people. Furthermore, neither symptoms nor abnormal contractions are definitively associated with histopathologic abnormalities of the esophagus.
Opioid use is associated with a nearly 5-fold increase in the risk of distal esophageal spasm, as well as other disorders of esophageal motility (1).
General reference
1. Niu C, Zhang J, Bapaye J, et al. Systematic Review With Meta-Analysis: Chronic Opioid Use Is Associated With Esophageal Dysmotility in Symptomatic Patients. Am J Gastroenterol. 2023;118(12):2123-2132. doi:10.14309/ajg.0000000000002410
Symptoms and Signs of Distal Esophageal Spasm
Sometimes, distal esophageal spasm is asymptomatic and is found incidentally.
When symptomatic, distal esophageal spasm typically causes substernal chest pain with dysphagia for both liquids and solids. Very hot or cold liquids may aggravate the pain. Dysphagia without pain may also be the primary presenting symptom. Over many years, this disorder rarely evolves into achalasia (with impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing).
Esophageal spasms can cause severe pain without dysphagia. This pain is often described as a substernal squeezing pain and may occur in association with exercise. Such pain may be similar to angina pectoris, and patients often present to the emergency department concerned they are having a heart attack.
Diagnosis of Distal Esophageal Spasm
Testing to exclude coronary ischemia
Barium swallow
High resolution esophageal manometry
Alternative diagnoses include coronary ischemia, which always needs to be excluded by appropriate testing (eg, ECG, cardiac biomarkers, stress testing—see diagnosis of acute coronary syndromes). Definitive confirmation of an esophageal origin for symptoms is difficult.
Barium swallow may show poor progression of a bolus and disordered, simultaneous contractions or tertiary contractions. Severe spasms may mimic the radiographic appearance of diverticula but vary in size and position. Typically, barium swallow is performed before manometry because it can be used to find other causes of symptoms and is less invasive.
High resolution esophageal manometry provides the most specific description of the spasms. At least 20% of test swallows must have premature peristalsis (a short distal latency of < 4.5 seconds to meet manometric criteria for distal esophageal spasm. However, spasms may not occur during testing (1).
If the primary presenting symptom is dysphagia rather than pain, endoscopy may be performed initially.
Esophageal scintigraphy and provocative tests with medications (eg, edrophonium chloride 10 mg IV) have not proved helpful.
Diagnosis reference
1. Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0. Neurogastroenterol Motil. 2021;33(1):e14058. doi: 10.1111/nmo.14058
Treatment of Distal Esophageal Spasm
Calcium channel blockers
Cessation of opioid use
Botulinum toxin injection
Sometimes surgical or endoscopic myotomy
Esophageal spasms are often difficult to treat, and controlled studies of treatment methods are lacking. Oral calcium channel blockers may be useful (1), as may proton pump inhibitors if concomitant gastroesophageal reflux disease is suspected (2). Anticholinergics, tricyclic antidepressants, nitroglycerin, and long-acting nitrates may also be tried but generally have limited success (). Anticholinergics, tricyclic antidepressants, nitroglycerin, and long-acting nitrates may also be tried but generally have limited success (3, 4).
Opioid use, if present, should be discontinued.
Rarely, a trial of injecting botulinum toxin type A into the esophagus and/or lower esophageal sphincter is performed.
If medical management fails, a myotomy may be considered. A surgical or peroral endoscopic extended myotomy of the esophagus has been tried in severe cases (1, 5, 6).
Treatment references
1. Roman S, Kahrilas PJ. Distal esophageal spasm. Curr Opin Gastroenterol. 2015;31(4):328-333. doi:10.1097/MOG.0000000000000187
2. Zaher EA, Patel P, Atia G, Sigdel S. Distal Esophageal Spasm: An Updated Review. Cureus. 2023;15(7):e41504. doi:10.7759/cureus.41504
3. Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med. 2018;131(9):1034-1040. doi: 10.1016/j.amjmed.2018.02.031
4. Vasireddy AR, Leggett CL, Kamboj AK. Esophageal Motility Disorders: A Concise Review on Classification, Diagnosis, and Management. Mayo Clin Proc. 2025;100(2):332-339. doi:10.1016/j.mayocp.2024.09.024
5. Leconte M, Douard R, Gaudric M, et al. Functional results after extended myotomy for diffuse oesophageal spasm. Br J Surg. 2007;94(9):1113-1118. doi: 10.1002/bjs.5761
6. Maradey-Romero C, Fass R. New therapies for non-cardiac chest pain. Curr Gastroenterol Rep. 2014;16(6):390. doi:10.1007/s11894-014-0390-4
