Esophageal Spasm (nutcracker esophagus) what you need to know

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

Also known as walnut esophagus or distal or diffuse esophageal spasm (DES), esophageal spasm is a rare disorder that affects about 1 in 100,000 people. It is not a life-threatening health problem, but it can cause serious discomfort and affect your quality of life.

Determining the cause of esophageal spasm is key to its management. This starts with understanding what an esophageal spasm feels like, what can trigger it, and when you should get help.

The symptoms of an esophageal spasm can resemble those of a heart attack, causing painful muscle contractions in the chest and upper abdomen. The pain is retrosternal (behind the sternum) and feels crushing, tight, or sharp. It starts in the chest and can move towards the back.

Dysphagia (difficulty swallowing) is another sign of esophageal spasm. You may feel as if an object is blocking your throat or chest when there is nothing—a sensation called globus hystericus.

In what is sometimes called diffuse or distal esophageal spasm, reflux of stomach acid or undigested food may also occur. Known as regurgitation, this can lead to vomiting and heartburn, a burning sensation in the chest. When chronic and severe, additional symptoms may include hoarseness and coughing.

Esophageal spasms can be episodic, although some have persistent, chronic episodes. Symptoms come and go, with attacks lasting from a few minutes to an hour or more. Symptoms often develop shortly after eating or drinking hot or cold things, but they can occur at any time. Because eating becomes difficult, chronic cases can cause unwanted weight loss.

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

Altered nerve activity

During normal swallowing, the muscles of the esophagus perform 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 happen automatically and are regulated by nerves, which activate and relax the muscles of the esophagus as needed.

Esophageal spasms occur when these nerves don’t fire and work together. This causes a mismatch between the excitatory signals that tell the muscles to contract and the inhibitory ones that relax them. The chemical nitric oxide plays a role in this process, with insufficient levels thought to trigger these muscle spasms.

gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD) is caused by dysfunction of the lower esophageal sphincter – the valve between the esophagus and the stomach. As a result, stomach acids back up, causing chronic symptoms, including:

• Mustard
• Chest pains
• Nausea
• Vomiting
• Difficulty swallowing (dysphagia)
• Chronic cough
• A hoarse voice

Some researchers believe that this constant exposure to stomach acids affects the nerves of the esophageal muscles, causing them to change their activity patterns and lead 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 (difficulty moving food through the body).

With spastic achalasia, the muscles of the esophagus do not contract during swallowing. The lower esophageal sphincter fails to relax, making it impossible to swallow solids or liquids. Often mistaken for GERD, common signs of spastic achalasia include:

• Mustard
• Dysphagia
• Regurgitation, the backflow of stomach acid into the esophagus
• Chest pains
• Night cough
• Whistling while eating
• Weight loss
• Noisy or labored breathing

Researchers believe that inhibition of nitric oxide may be a trigger for both esophageal spasm and spastic achalasia. There are cases where the former develops into severe forms of the latter.

Triggers

Although there is still debate about the exact causes of esophageal spasms, researchers have identified potential triggers. This problem can occur independently of eating or drinking, but for many the attacks begin after eating very hot or cold food.

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

Risk factors

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

You should contact a healthcare professional if you have multiple attacks of esophageal spasm symptoms or if you experience them for two weeks or more. Because sharp chest pains can also mean a heart attack, seek emergency care if you have them for more than five minutes.

Health professionals will need to rule out a heart attack or heart-related causes. To do this, they may monitor your heart with an electrocardiogram (ECG), angiogram, or other imaging and clinical tests.

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

• endoscopy: Health care providers pass a flexible tube with a camera down the esophagus to check for physical obstructions or other problems.
• barium swallow: After they swallow barium, a radioactive compound, health professionals take an X-ray. Narrowed parts of the esophagus become more visible on imaging.
• Esophageal manometry: Healthcare professionals place a catheter with sensors in the esophagus to monitor muscle movements when you swallow.

The goal of treating esophageal spasms is to stop the irregular activity of the esophageal muscles. Symptoms decrease when the muscles relax.

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

Home Remedies

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

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

Medicines

Medicines for esophageal spasms either work to relieve symptoms in occasional cases or to prevent attacks in chronic ones. This may include:

• Proton pump inhibitors (PPIs): Medicines such as Prilosec (omeprazole) and Prevacid (lansoprazole) relieve 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 seizures.
• Calcium channel inhibitors: A type of blood pressure medication, calcium channel blockers such as Cardizem (diltiazem) relax the muscles of the esophagus, stopping attacks and relieving pain.
• Tricyclic antidepressants: Tricyclic antidepressants such as Tofranil (imipramine) act on the nerves of the esophageal muscles to stop pain and relieve symptoms.
• Botox injection: Botulinum toxin A (Botox) injections put the nerves in the esophagus to “sleep,” temporarily stopping the spasms. Considering more severe or chronic cases, the effects of each treatment last for about a year.

Surgery

In very severe and severe 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 by gravity.

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

• Cold foods, such as ice cream or ice cream
• Hot liquids, such as hot tea or broth
• Spicy food
• Fatty foods, such as red meat or bacon
• Beverages that contain caffeine, such as coffee, black or green tea, and certain juices

If you are prone to seizures, it may help to keep a journal. Keep track of your symptoms, foods that trigger seizures, and any medications you take. Not only will you have a better understanding of your condition, but you will have useful information for your doctor.

Esophageal spasm occurs when the muscles of the esophagus contract uncontrollably, causing severe chest pain, difficult or painful swallowing, heartburn, and other symptoms. These cramps are rare and may only occur occasionally.

Although this condition may look like a heart attack, it is not dangerous or fatal. Researchers aren’t sure what causes it, but they’ve linked it to abnormal nerve activity among the muscles of the esophagus.

Medicines can help treat and prevent this condition, and surgery is reserved for very severe cases.