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Peppermint oil may give symptomatic relief with dysphagia and chest pain

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Peppermint can help with the difficulty swallowing and non-cardiac chest pain experienced by some patients with disorders of the oesophagus, report investigators at the Medical University of South Carolina (MUSC). Of the 38 patients enrolled in the MUSC pilot study, 63% overall reported improvement of symptoms. Patients were recruited from the Oesophageal Disorders Clinic at the MUSC Health Digestive Disease Centre.

“Peppermint oil is an established agent in the treatment of irritable bowel syndrome. We tried to examine its effect on patients with swallowing and chest pain issues with no apparent cause,” says Dr Mohamed Khalaf, an oesophageal disorders research fellow at the MUSC Health Digestive Disease Centre and first author on the article.

“Our findings suggest that peppermint may help prevent these symptoms by relaxing the smooth muscle in the lower oesophagus,” says Dr Donald O Castell, a professor emeritus in the MUSC College of Medicine, a nationally recognised gastroenterologist, and senior author on the article.

Peppermint oil has been known to have therapeutic effects in multiple disorders due to its muscle-relaxing properties. However, only two previous studies have investigated its role in the upper digestive tract.

The MUSC study found that patients who took peppermint oil tablets before eating felt better after meals than those who did not. Those with both non-cardiac chest pain and unobstructed difficulty swallowing saw the most benefits: 73% of them reported feeling better. Of patients with just one of the symptoms, those with non-cardiac chest pain had a more positive response from the peppermint oil (63%) than those with difficulty swallowing (53%).

The results were even better among patients with spastic disorders of the oesophagus: 83% reported feeling better or slightly better. Although less well-known than oesophageal disorders such as acid reflux, spastic disorders of the oesophagus can also disrupt a patient’s life. In these disorders, the oesophagus undergoes painful spasms that can interfere with eating. Because the spasms occur only from time to time, these disorders are difficult to diagnose and treat.

Current standard of care calls for these disorders involves trying multiple drugs, including tricyclic antidepressants and calcium channel blockers, and hoping that one works.

Peppermint offers an attractive first line of defence for these patients, who experience intermittent symptoms, because they can take it freely as symptoms occur. “In this study, patients who had experienced difficulty swallowing took two pieces of a commercially available peppermint right before meals. Those with chest pain took the peppermint tablets as needed,” says Khalaf.

This study highlights the effects of the so-called Charleston Approach, which advocates a “start low and go slow” treatment strategy. The Charleston Approach differs from current standard of care in that it uses peppermint oil as a first attempt to relieve symptoms.

Castell and Khalaf caution that patients must first be examined by a doctor to rule out heart disease and undergo a procedure known as an endoscopy to rule out obstruction before they are offered peppermint as a first-line treatment. Endoscopy involves inserting a flexible tube fitted with a light and camera into the oesophagus.

One of the drawbacks of the study was that researchers did not know the precise dosage of peppermint being given since it was a commercial candy (only one type of which was effective) with a proprietary recipe. Another was the study relied on self-reporting by patients to determine whether symptoms improved.

Although the preliminary findings of this study are promising, they need to be confirmed in a trial that compares outcomes in patients who receive a specific dose of peppermint oil and those who receive only a placebo.

In the meantime, however, patients who have been diagnosed as having spastic disorders of the oesophagus and who have no heart disease or obstruction can try using peppermint to see if it relieves their symptoms.

“Given the safety profile, low cost, and widespread availability, there are no risks from empirical use of peppermint oil,” says Khalaf.

Abstract
Background: Due to its smooth muscle relaxing properties, peppermint oil (PO) may relieve dysphagia and chest pain due to esophageal motility disorders.
Aim: To explore the impact of PO on dysphagia and/or chest pain in patients referred for motility testing.
Methods: Patients initiated on PO for dysphagia and/or chest pain from 2013 to 2016 were identified. We excluded patients with obstructing esophageal lesions, patients lost to follow-up, and those with preexisting cardiac conditions. Concentrated PO was given as commercially available dissolvable peppermint tablets; two tablets before meals were prescribed to patients with dysphagia and on an as-needed basis for patients with chest pain. Patient-reported symptom response was assessed using a modified five-point Likert scale.
Results: Thirty-eight patients were included. Twenty-four patients (63%) reported improvement; 12 were much better and 12 were slightly better. Fourteen experienced no change and none reported feeling worse. Based on pre-treatment HRM, patients with distal esophageal spasm (DES) (n = 10) and esophagogastric junction outflow obstruction (EGJOO) (n = 8) appeared to demonstrate the best subjective improvement (83% and 100%, respectively) (P < 0.05).
Conclusion: PO appears to provide symptomatic relief in some patients with dysphagia and CP. Presence of a well-defined manometric disorder, particularly DES or EGJOO, appeared to predict response.

Authors
Mohamed HG Khalaf, Sejal Chowdhary, B Joseph Elmunzer, Puja Sukhwani Elias, Donald Castel

Medical University of South Carolina material
Digestive Diseases and Sciences abstract


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