Conditions · Gastroenterology and hepatology

Distal oesophageal spasm and hypercontractile oesophagus !

Disorders in which the oesophagus squeezes too early or too hard. They cause chest pain that can mimic a heart attack and trouble swallowing.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

Primary motility disorders of the oesophageal smooth muscle. In distal oesophageal spasm, contractions are premature and uncoordinated; in hypercontractile (jackhammer) oesophagus, contractions are extremely strong. Both cause chest pain and dysphagia.

Who gets it

Uncommon, found in a small share of people studied with manometry for dysphagia or non-cardiac chest pain; more often in women and in middle-aged and older adults. In Colombia, Chagas disease must be considered in people from endemic areas with an oesophageal motility disorder.

Causes

Usually idiopathic
Impaired inhibitory nerve function (nitric oxide) in the myenteric plexus in distal spasm
Excess cholinergic drive in hypercontractile oesophagus
Gastro-oesophageal reflux may trigger or coexist with it
Opioid use can produce a similar pattern

Risk factors

Female sex and age over 50
Gastro-oesophageal reflux
Chronic opioid use
Anxiety and visceral hypersensitivity (affect symptom perception)

Pathophysiology

Normal peristalsis spreads down the oesophagus in sequence because inhibitory nerves delay contraction in the distal segment. In distal oesophageal spasm, loss of this inhibition makes the distal oesophagus contract prematurely or simultaneously, which blocks the bolus and causes pain. In hypercontractile oesophagus, contractions are of excessive vigour. In both, the lower oesophageal sphincter usually relaxes normally, unlike achalasia, although the disorders overlap and may progress to it.

Classification

Distal oesophageal spasm: premature contractions in at least 20% of swallows, with normal sphincter relaxation (Chicago classification)
Hypercontractile (jackhammer) oesophagus: very high contraction vigour in at least 20% of swallows
Both are major disorders of peristalsis on high-resolution manometry

Symptoms and signs

Retrosternal chest pain, squeezing, that may spread to the back, neck or arms
Intermittent dysphagia to both solids and liquids
Symptoms triggered by very hot or cold drinks or by stress
Regurgitation and heartburn in some
A feeling of food sticking in the chest

Diagnosis

Clinical: Suspected in a person with intermittent dysphagia and chest pain after a cardiac cause has been excluded.
Tests: ECG and troponin first in any acute chest pain. High-resolution oesophageal manometry confirms the diagnosis and distinguishes it from achalasia. Upper endoscopy excludes structural disease, eosinophilic oesophagitis and reflux injury. Chagas serology in people from endemic areas.
Imaging: Barium swallow may show a «corkscrew» or «rosary bead» oesophagus in distal spasm, but it can be normal. Cardiac testing (stress test or coronary imaging) when angina is possible.

Differential diagnosis

Angina or acute coronary syndrome
Achalasia, including type III (spastic) achalasia
GERD and reflux-related chest pain
Eosinophilic oesophagitis
Chagasic oesophageal disease
Oesophageal cancer or stricture

Goal of treatment

Reduce chest pain and dysphagia after excluding cardiac disease, treating any reflux and avoiding unnecessary invasive procedures.

Treatment

Conservative: Reassurance and explanation, avoiding very hot or cold drinks and stopping opioids when possible.
Medical: Proton pump inhibitors when reflux contributes. Smooth muscle relaxants (calcium channel blockers, nitrates, phosphodiesterase-5 inhibitors) and tricyclic antidepressants or other neuromodulators to reduce pain perception.
Procedure: Botulinum toxin injection into the distal oesophagus, pneumatic dilation, or peroral endoscopic myotomy (POEM) for severe, refractory cases.
Follow-up: Nursing focus: treat every chest pain as cardiac until proven otherwise, monitor blood pressure and headache with smooth muscle relaxants, and watch for food impaction.

Complications

Food bolus impaction
Weight loss when dysphagia is severe
Progression to achalasia in a minority
Anxiety and repeated emergency visits for chest pain

Prognosis

Benign and usually chronic with fluctuating symptoms. It does not shorten life; many people improve with reassurance and medicines, and a few need endoscopic treatment.

Test yourself

Think of the answer, then tap the question to see it.

What must be excluded first in a patient with chest pain suspected of oesophageal spasm?

Cardiac ischaemia (acute coronary syndrome or angina) with ECG, troponin and cardiac testing.

Which test confirms distal oesophageal spasm?

High-resolution oesophageal manometry showing premature contractions with normal sphincter relaxation.

What is the classic barium swallow appearance of distal oesophageal spasm?

A «corkscrew» or «rosary bead» oesophagus.

How does distal oesophageal spasm differ from achalasia on manometry?

In spasm the lower oesophageal sphincter relaxes normally; in achalasia it fails to relax.

What is jackhammer oesophagus?

A hypercontractile oesophagus with extremely vigorous contractions on manometry.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Esophageal Motility Disorders - Gastroenterology - MSD Manual Professional Edition (MSD Manual Professional Edition, 2025).

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Representative model, for educational purposes only.

Esophagus highlighted on the Durgical 3D model