Esophageal Spasms & Strictures

What are esophageal spasms and strictures?

An esophageal spasm is a rare disorder characterized by abnormal muscle contractions in the esophagus.

The esophagus is the narrow muscular organ that connects the mouth to the stomach and through which foods and liquids pass after being swallowed. After food is chewed and swallowed, the lump of food moves downward through the esophagus. If the esophagus is functioning normally, peristalsis, or a wave of coordinated contractions, takes place.

However, people with distal esophageal spasm may experience simultaneous contractions in long sections of the esophagus instead of a coordinated wave of contractions. The contractions may be irregular, uncoordinated, or unusually powerful, keeping food or liquids from moving normally down the esophagus.

People who have esophageal spasms may experience:

• Chest pain which occasionally may be severe enough to be mistaken for a heart attack
• Difficulty with swallowing (dysphagia) foods or liquids
• A feeling that something is stuck in the throat

There are two main types of spasms:

• Diffuse (or distal) esophageal spasms are uncoordinated muscle contractions that occur throughout the lower two-thirds of the esophagus.
• Nutcracker esophagus is a condition in which the muscle contractions are coordinated but are too strong, causing severe pain.

What is an esophageal stricture?

An esophageal stricture occurs when the esophagus becomes abnormally narrow. Benign (non-cancerous) strictures may occur due to buildup of fibrous tissue and collagen deposits due to ulcers or chronic inflammation of the esophagus.

There are two major types of strictures: simple and complex.

• Simple is symmetric with a diameter of more than 12 mm.
• Complex is asymmetric and has a diameter of less than 12 mm.

People with esophageal strictures also have difficulty swallowing solid foods, but generally do not have problems with swallowing liquids.

What causes esophageal spasms and strictures?

No one is sure exactly what causes esophageal spasms. The nerves that regulate peristalsis, the series of muscle contractions in the esophagus, might not work properly. Sometimes spasms are triggered when a person eats hot or cold foods and beverages. However, spasms can also occur in the absence of eating or drinking.

The most common type of esophageal stricture is a peptic stricture resulting from gastroesophageal reflux disease (GERD). Unless it is treated, GERD can cause scarring and narrowing of the lower esophagus. However, now that more effective medications, such as proton pump inhibitors, have been developed to treat GERD, strictures in the lower esophagus resulting from acid reflux are less common.

Strictures may also result from:

• Radiation treatment for cancer of the head, neck, or chest
• Surgery to treat esophageal cancer or Barrett’s esophagus
• Treatment of enlarged veins in the esophagus
• Swallowing harmful chemicals or objects
• An allergic condition called eosinophilic esophagitis

How are esophageal spasms and strictures diagnosed?

If symptoms such as difficulty swallowing or a burning sensation in the throat or chest are present, your doctor may perform various tests to determine the cause. These tests may include:

• Barium swallow - which requires a patient to swallow a solution containing barium. X-rays are taken while the barium moves down the esophagus. If a stricture is present, the barium may become stuck or slows down.
• Endoscopy - if the doctor suspects that a structural abnormality is present. A narrow tube called an endoscope is inserted into the esophagus. The endoscope has a light and tiny camera at one end so the doctor can observe the inside of the esophagus.
• Esophageal manometry - if no structural abnormality is detected. It is performed to measure pressure waves inside the esophagus. The presence of unusually large numbers of simultaneous contractions in the lower esophagus is the major indicator of spasms.
• Esophageal motility test - measures muscular strength and coordination. The test is performed by inserting a small tube through the nose into the esophagus. The tube contains pressure-sensitive transducers, which remain in the esophagus after the tube is withdrawn. The patient swallows a small amount of water (about a teaspoon) at regular intervals to allow the transducers to measure the contractions during peristalsis. The test can also detect whether there is an abnormality in the valve at the lower end of the esophagus (lower esophageal sphincter).

How are esophageal spasms and strictures treated?

There are a variety of methods available for treating simple benign (non-cancerous) esophageal strictures.

Dilation is used to widen the esophageal passageway to relieve dysphagia (difficulty swallowing). The technique uses dilators (long plastic or rubber cylinders of different sizes) to stretch the opening. Dilators with gradually increasing diameters are inserted through the mouth, sometimes over a guide wire.

Balloons may be passed through an endoscope and inflated to stretch the opening. Medication to reduce gastric acid production may be given before the procedure if the stricture is caused by GERD.

Complex strictures are often seen after radiation therapy to treat cancer of the head, neck or chest, or in cases where caustic substances were ingested. In cases for patients with malignant cancer, temporary metal stents (expandable tubes) may be used instead of balloon dilation to keep the esophagus open.

Various treatment options for spasms of the lower (distal) esophagus may include:

• Oral medications: Calcium channel blockers and nitrates (sublingual nitroglycerin) help to relax the smooth muscle of the lower esophagus. Hyoscamine may also be taken under the tongue to relieve spasms. Sometimes, pain modulators such as tricyclic antidepressants are used to relieve the pain.
• Botulinum toxin: Injections of botulinum toxin into the smooth muscle of the lower esophagus may inhibit the transmission of nerve impulses, leading to relaxation.
• Surgery: In some rare cases, patients who do not respond to treatment with medications may have to undergo an operation called a myotomy, in which a long incision is made in the lower esophageal sphincter and muscle to control spasms.
• Relaxed breathing, biofeedback or hypnosis
• Warm water: Drinking a glass of warm water may help relieve symptoms in less severe cases.

In most cases, patients can be treated successfully and the disorder will not lead to other serious conditions.