Diffuse esophageal spasm medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Madhu Sigdel M.B.B.S.[2]

Overview

The mainstay of treatment for DES is medical therapy with calcium channel blockers, and/or tricyclic antidepressants.

Medical Therapy

• Patients with DES are treated with calcium channel blockers if dysphagia is predominant , whereas patients with predominant chest pain are treated with either calcium channel blockers or tricyclic antidepressants.
• Nitrate releasing drugs and local injection of Botox toxin are used if above measures fail.
• Proton pump inhibitors are used in secondary DES.

Diffuse esophageal spasm

Treatment of acute episode of DES is by sublingual hyoscyamine 0.125mg or nifedipine 10mg or nitroglycerine 0.3mg.

• 1 Primary DES
  • 1.1 Adult
    • Preferred regimen (1): Diltiazem 180-240 mg PO q24h for 7-10 days. (Contraindications: Hypersensitivity, AV block (2nd or 3rd degree), hypotension, acute MI)
    • Preferred regimen (2): Imipramine 25-50 mg at bedtime for 14-21 days.
    • Alternative regimen (1): Isosorbide 10 mg or sildenafil 50 mg PO as needed.
  • 1.2 Pediatric
    • • Preferred regimen (1): Diltiazem 1.5-2mg/kg 50 mg/kg PO in 3-4 divided doses.
      • Preferred regimen (2): Imipramine 10-25 mg PO per day at bedtime. (maximum, 50mg/day if 6 years to < 12 years and 75mg/day if = or > 12 years).

• 2 Secondary DES (treatment of GERD)
  • 2.1 Adult
    • Preferred regimen (1): Omeprazole 20mg PO q24h for 4 weeks
  • 2.2 Pediatric age 1 to 16years
    • Preferred regimen (1): 5kg to <10 kg; Omeprazole 5mg PO q24h for 4 weeks
    • 10kg to 20 kg; Omeprazole 10mg PO q24h for 4 weeks
    • ≥ 20 kg: Omeprazole 20mg PO q24h for 4 weeks.

• Refractory cases
• In cases refractory to above treatment options, endoscopic injection of Botulinum toxin 100U is the next medical therapy. Complications of botox injection are chest pain/ heart burn, epigastric pain and rarely acute mediastinitis.