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{{Diffuse esophageal spasm}}
{{CMG}}; {{AE}} {{MSI}}
{{CMG}}; {{AE}} {{MSI}}


==Overview==
==Overview==
The mainstay of treatment for DES is medical therapy with calcium channel blockers, and/or tricyclic antidepressants.
The mainstay of treatment for DES is medical therapy with [[Calcium channel blocker|calcium channel blockers]], and/or [[Tricyclic antidepressant|tricyclic antidepressants]].


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*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 blocker|calcium channel blockers]] or [[Tricyclic antidepressant|tricyclic antidepressants]].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Nitrate releasing drugs and local injection of [[Botulinum toxin|Botox]] toxin are used if above measures fail.
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*[[Proton pump inhibitor|Proton pump inhibitors]] are used in secondary DES.<ref name="pmid18005367">{{cite journal| author=Grübel C, Borovicka J, Schwizer W, Fox M, Hebbard G| title=Diffuse esophageal spasm. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 2 | pages= 450-7 | pmid=18005367 | doi=10.1111/j.1572-0241.2007.01632.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18005367  }}</ref><ref name="pmid22215281">{{cite journal| author=Roman S, Kahrilas PJ| title=Distal esophageal spasm. | journal=Dysphagia | year= 2012 | volume= 27 | issue= 1 | pages= 115-23 | pmid=22215281 | doi=10.1007/s00455-011-9388-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22215281  }}</ref>
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Diffuse esophageal spasm===
===Disease Name===
'''Treatment of acute episode of DES is by [[sublingual]] [[hyoscyamine]] 0.125mg or [[Nifedipine|nifedipin]]<nowiki/>e 10mg or [[Nitroglycerin|nitroglycerine]] 0.3mg'''.
* '''1 Primary DES'''
** 1.1 '''Adult'''
*** Preferred regimen (1): [[drug name|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 dinitrate|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).     


* '''1 Stage 1 - Name of stage'''
* '''2 Secondary DES (treatment of GERD)'''
** 1.1 '''Specific Organ system involved 1'''
**2.1 '''Adult'''
*** 1.1.1 '''Adult'''
*** Preferred regimen (1): [[Omeprazole]] 20mg PO q24h for 4 weeks
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**2.2 '''Pediatric age 1 to 16years'''
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
*** Preferred regimen (1): 5kg to <10 kg; [[Omeprazole]] 5mg PO q24h for 4 weeks
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
*** 10kg to 20 kg; [[Omeprazole]] 10mg PO q24h for 4 weeks
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
*** ≥ 20 kg: [[Omeprazole]] 20mg PO q24h for 4 weeks.
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
* ''' Refractory cases'''
** 2.1 '''Specific Organ system involved 1 '''
* 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.<ref name="pmid27337985">{{cite journal| author=van Hoeij FB, Tack JF, Pandolfino JE, Sternbach JM, Roman S, Smout AJ et al.| title=Complications of botulinum toxin injections for treatment of esophageal motility disorders†. | journal=Dis Esophagus | year= 2017 | volume= 30 | issue= 3 | pages= 1-5 | pmid=27337985 | doi=10.1111/dote.12491 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27337985 }}</ref>
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2 '''Other Organ system involved 2'''
**: '''Note (1):'''
**: '''Note (2):'''
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Latest revision as of 14:25, 4 December 2017

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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

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.[3]

References

  1. ↑ Grübel C, Borovicka J, Schwizer W, Fox M, Hebbard G (2008). "Diffuse esophageal spasm". Am J Gastroenterol. 103 (2): 450–7. doi:10.1111/j.1572-0241.2007.01632.x. PMID 18005367.
  2. ↑ Roman S, Kahrilas PJ (2012). "Distal esophageal spasm". Dysphagia. 27 (1): 115–23. doi:10.1007/s00455-011-9388-3. PMID 22215281.
  3. ↑ van Hoeij FB, Tack JF, Pandolfino JE, Sternbach JM, Roman S, Smout AJ; et al. (2017). "Complications of botulinum toxin injections for treatment of esophageal motility disorders†". Dis Esophagus. 30 (3): 1–5. doi:10.1111/dote.12491. PMID 27337985.

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