Spasm

This page covers two related problems in the body of the esophagus, the long stretch between the two sphincters. Normally a swallow sends one calm wave down the tube, squeezing food along.

In distal esophageal spasm the lower part of the esophagus squeezes too early, before the wave should get there. In hypercontractile esophagus the squeezes are far too strong. Jackhammer esophagus is one form of it, with repeated, long contractions¹. In both, the sphincter at the bottom relaxes normally, which is what separates them from achalasia^2,3.

The cause is not clear. It can be a problem with the esophagus itself, a side effect of opioid painkillers, or a reaction to reflux³. It is uncommon: spastic problems turn up in only 1 to 2 percent of people who have a manometry test³.

Chest pain behind the breastbone, and trouble swallowing, that come and go^1,4. Food can feel stuck in the chest, or sometimes higher, in the throat⁴.

In one review of distal esophageal spasm, 55% of patients had trouble swallowing and 29% had chest pain⁵. In jackhammer esophagus, trouble swallowing was the most common symptom (64%), the average age at diagnosis was 61, and 65% of patients were women⁶.

From a heart problem. Chest pain always needs the heart checked first. Heart disease is far more common than esophageal spasm, so doctors rule it out before looking at the esophagus. Once the heart is cleared, the pain is called non-cardiac chest pain^3,4.

From achalasia. On manometry, the lower sphincter relaxes normally in spasm and fails to relax in achalasia¹. Type III achalasia also has spasm-like squeezing, and some experts see the two as neighbours on the same spectrum^2,3.

From reflux. Reflux and spasm can go together. In one group of 108 people with distal esophageal spasm, 34% had too much acid in the esophagus. Reflux can set spasm off, so it is usually treated first³.

• Heart tests first, when chest pain is a symptom³.
• Upper endoscopy, a camera examination of the food pipe, to rule out a blockage or inflammation, such as eosinophilic esophagitis³.
• High-resolution manometry. A thin tube measures pressure while you swallow. Doctors use the results alongside your symptoms. Distal esophageal spasm is diagnosed when at least 20% of test swallows come too early, and hypercontractile esophagus when at least 20% are far too strong¹.
• Barium swallow. It sometimes shows a corkscrew shape, but it is not enough on its own³.

Opioid painkillers can cause the same pattern on manometry, so a clinician may discuss changing them before repeating the test. Do not stop a prescribed painkiller on your own³. The person to ask for is a gastroenterologist, and the test to ask about by name is high-resolution manometry.

• Monitoring with a clinician. After assessment, a clinician may recommend watching mild symptoms. In one long-term study, symptoms improved on their own over 3 to 10 years³.
• Treating reflux. A 6 to 8 week trial of acid medicine if reflux may be the trigger³.
• Muscle relaxants. Calcium channel blockers, nitrates or sildenafil. Side effects such as headache and dizziness limit them³.
• Low-dose antidepressants. When pain is the main problem, these can calm the sensitivity of the esophagus rather than the squeezing itself. The evidence comes mostly from small studies³.
• Botox. Injected at several levels of the lower esophagus. About half improve at one month and about 30% at one year³.
• POEM. Cutting the muscle from the inside, through the mouth. It is kept for the few people who have not improved with anything else^1,3.

• POEM works for most of the few who need it. In a 2024 meta-analysis of 11 studies with 271 patients, 97.8% of people with distal esophageal spasm did well (95% CI 90.9 to 100), compared with 81.2% of people with hypercontractile esophagus (95% CI 73.5 to 88.8). About 19% developed new heartburn afterwards⁷.
• Jackhammer esophagus is harder. In a pooled analysis, 82% did well after POEM (95% CI 75 to 90) and 63% with medicines (95% CI 47 to 79)⁶. In a longer follow-up of 42 patients after POEM, 64% were still doing well at two years⁸.
• How sure we can be. The POEM evidence above comes mainly from small observational studies. In a randomized study of 23 people with hypercontractile esophageal disorders, Botox did not improve symptoms more than a sham procedure at three months. Treatment benefits remain uncertain. Experts reserve procedures for people who do not improve with other care^3,9.

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