Year 2025 / Volume 117 / Number 11
Editorial
Is chest pain in achalasia always due to spasm?

627-629

DOI: 10.17235/reed.2025.11227/2025

Julio Pérez de la Serna y Bueno, Antonio Ruiz de León San Juan,

Abstract
Chest pain is a common symptom in achalasia, particularly in younger patients, those with a shorter disease duration, and type III achalasia. Its frequency and intensity vary, sometimes resembling angina. It may occur independently of eating, drinking, or sleeping. Despite treatment, long-term resolution rates are only 20-25 %, and up to 8 % of treated patients develop new-onset pain. The mechanisms behind chest pain in achalasia remain unclear. Pain occurs both before and after treatment and is not always linked to esophageal spasms. Possible causes include food retention, gas trapping, esophageal hypersensitivity, and persistent high-amplitude contractions in type III achalasia. Mechanisms may involve esophageal mechanoreceptor stimulation, nociceptor activation, and longitudinal muscle hyperactivity. However, in type I and II achalasia, contractions are weak or absent, and many pain episodes are not preceded by esophageal spasms. Studies indicate that air and saliva accumulation can provoke pain, sometimes relieved by endoscopic food removal or supragastric belching. Balloon distension tests and impedance-pH monitoring support the role of esophageal distension in pain generation. Attributing chest pain solely to esophageal spasms oversimplifies the issue. Once cardiovascular causes are ruled out, endoscopy, manometry, and pH monitoring help identify underlying mechanisms. Attributing chest pain solely to esophageal spasm oversimplifies the issue. Once cardiovascular causes are ruled out, diag nostic tools such as endoscopy, manometry, and pH monitoring help identify the underlying mechanism. A tailored treatment approach is essential to avoid ineffective or unnecessary therapies, such as prolonged use of antispasmodics or neuromodulators, ensuring better long-term symptom management.
New comment
Comments
No comments for this article
References
1. Eckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: Patient characteristics and clinical course. Gastroenterology. 1999; 116:1300–1304.
2. Olvera-Prado H, Peralta-Figueroa J, Narváez-Chávez S, et al. Predictive factors associated with the persistence of chest pain in post-laparoscopic myotomy and fundoplication in patients with achalasia. Front Med (Lausanne). 2022 Oct 14;9:941581. doi: 10.3389/fmed.2022.941581.
3. Sasaki A, Obuchi T, Nakajima J, et al. Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long-term outcomes and effect on chest pain. Dis Esophagus. 2010 May;23(4):284-9. doi: 10.1111/j.1442-2050.2009.01032.x.
4. Papo M, Mearin F, Castro A, et al. Chest pain and reappearance of esophageal peristalsis in treated achalasia. Scand J Gastroenterol. 1997;32:1190–4. doi: 10.3109/00365529709028145.
5. Nylander DL. Chest pain in achalasia is an age-dependent phenomenon. Gastroenterology. 1999; 117:1259. doi: 10.1016/S0016-5085(99)70429-4.
6. Perretta S, Fisichella P M, Galvani C, et al. Achalasia and chest pain: effect of laparoscopic Heller myotomy. J Gastrointest Surg. 2003; 7: 595–8.
7. Omura N, Kashiwagi H, Tsuboi K, et al. Therapeutic effects of a laparoscopic heller myotomy and Dor fundoplication on the chest pain associated with achalasia. Surg Today. 2006; 36:235–40. doi: 10.1007/s00595-005-3122-4.
8. Arain MA, Peters JH, Tamhankar AP, et al. Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. J Gastrointest Surg. 2004; 8:328– 34. doi: 10.1016/j.gassur.2003.09.011
9. Omura N, Kashiwagi H, Yano F, et al. Effect of laparoscopic esophagomyotomy on chest pain associated with achalasia and prediction of therapeutic outcomes. Surg Endosc. 2011; 25:1048–53. doi: 10.1007/s00464-010-1314-5.
10. Wuller C, Bessell JR, Watson DI. Chest pain before and after laparoscopic cardiomyotomy for achalasia. ANZ J Surg. 2011; 81:590–594. doi: 10.1111/j.1445-2197.2010.05577.x.
11. Nicodème F, de Ruigh A, Xiao Y, et al. A comparison of symptom severity and bolus retention with Chicago classification esophageal pressure topography metrics in patients with achalasia. Clin Gastroenterol Hepatol. 2013 Feb;11(2):131-7; quiz e15. doi: 10.1016/j.cgh.2012.10.015..
12. Hatafuku T, Maki T, Thal A P. Fundic patch operation in the treatment of advanced achalasia of the esophagus. Surg Gynecol Obstet. 1972; 134: 617–24.
13. Savarino EV, Salvador R, Ghisa M, et al. Research gap in esophageal achalasia: a narrative review. Dis Esophagus. 2024 Jul 31;37(8):doae024. doi: 10.1093/dote/doae024. PMID: 38525929.
14. Wolff R R, Defilippi CC. Nuevas técnicas para el estudio de la función esofágica. Gastroenterol. latinoam 2008; 19 (3): 228-233.
15. Sanderson DR, Ellis FH Jr, Schlegel JF, et al. Syndrome of vigorous achalasia: clinical and physiologic observations. Dis Chest. 1967; 52:508–517.
16. Bondi JL, Godwin DH, Garrett JM. “Vigorous’’ achalasia. Its clinical interpretation and significance. Am J Gastroenterol. 1972; 58:145–154.
17. Bramer S, Ladell A, Glatzel H, et al. Medical management of painful achalasia: a patient-driven systematic review. Dis Esophagus. 2024 Apr 27;37(5): doae005. doi: 10.1093/dote/doae005.
18. Holloway R. Esophageal Ultrasonography: A New View on Esophageal Motility. Am J Gastroenterol. 2007; 102: 146-148.
19. Balaban D H, Yamamoto Y, Liu J, et al. Sustained esophageal contraction: a marker of esophageal chest pain identified by intraluminal ultrasonography. Gastroenterology. 1999; 116: 29-37. doi: 10.1016/s0016-5085(99)70225-8.
20. Barish CF, Castell DO, Richter JE. Graded esophageal balloon distention. A new provocative test for noncardiac chest pain. Dig Dis Sci. 1986 Dec;31(12):1292-8.
21. Remes-Troche JM, Attaluri A, Chahal P, et al. Barostat or dynamic balloon distention test: which technique is best suited for esophageal sensory testing? Dis Esophagus. 2012 Sep-Oct;25(7):584-9.
22. Carlson DA, Kahrilas PJ, Pandolfino JE. Repetitive antegrade contractions on high-resolution manometry: A physiologic pattern related to sustained esophageal distention in Abelchia. Neurogastroenterol Motil. 2025 Feb;37(2):e14934. doi: 10.1111/nmo.14934.
23. Alcala-Gonzalez LG, Aguilar-Cayuelas A, Quiroga S, et al. Recurrent symptoms after achalasia treatment: The value of impedance analysis. United European Gastroenterol J. 2024 Oct 28. doi: 10.1002/ueg2.12692.
24. Bastian RW, Smithson ML. Inability to belch and associated symptoms due to retrograde cricopharyngeus dysfunction: diagnosis and treatment. OTO Open. 2019; 15;3(1):2473974X19834553. doi: 10.1177/2473974X19834553.
25. Aggarwal M, McMichael J, Murthy SC, et al. Neuromodulators are effective for treatment of spastic chest pain after heller myotomy for achalasia. J Neurogastroenterol Motil. 2021 Oct 30;27(4):655-656. doi: 10.5056/jnm21113.
Related articles

Letter

A case of achalasia associated with early esophageal cancer

DOI: 10.17235/reed.2024.10177/2023

Digestive Diseases Image

Type II achalasia with post-POEM recovery of esophageal motility

DOI: 10.17235/reed.2023.9420/2022

Digestive Diseases Image

Black esophagus

DOI: 10.17235/reed.2022.9217/2022

Letter

Infection with SARS-CoV-2 as a potential achalasia trigger

DOI: 10.17235/reed.2022.8975/2022

Digestive Diseases Image

Acute respiratory failure secondary to megaesophagus: think beyond COVID-19

DOI: 10.17235/reed.2022.8847/2022

Digestive Diseases Image

Severe drug esophagitis in a patient with achalasia

DOI: 10.17235/reed.2022.8476/2021

Digestive Diseases Image

Severe respiratory failure secondary to megaesophagus due to terminal achalasia

DOI: 10.17235/reed.2020.7672/2020

Original

Implementation of a peroral endoscopic myotomy program

DOI: 10.17235/reed.2020.7116/2020

Letter

Hypertensive panesophageal pressurization in type II achalasia

DOI: 10.17235/reed.2019.6414/2019

Letter

An unexpected cause of dysphagia: pleural mesothelioma

DOI: 10.17235/reed.2019.6024/2018

Citation tools
Pérez de la Serna y Bueno J, Ruiz de León San Juan A. Is chest pain in achalasia always due to spasm?. 11227/2025


Download to a citation manager

Download the citation for this article by clicking on one of the following citation managers:

Metrics
This article has received 54 visits.
This article has been downloaded 0 times.

Statistics from Dimensions


Statistics from Plum Analytics

Publication history

Received: 22/03/2025

Accepted: 10/04/2025

Online First: 12/05/2025

Published: 11/11/2025

Article Online First time: 51 days

Article editing time: 234 days


Share
This article hasn't been rated yet.
Reader rating:
Valora este artículo:




Asociación Española de Ecografía Digestiva Sociedad Española de Endoscopia Digestiva Sociedad Española de Patología Digestiva
The Spanish Journal of Gastroenterology is the official organ of the Sociedad Española de Patología Digestiva, the Sociedad Española de Endoscopia Digestiva and the Asociación Española de Ecografía Digestiva
Cookie policy Privacy Policy Legal Notice © Copyright 2025 y Creative Commons. The Spanish Journal of Gastroenterology