Updated: 5/31/2019

Nutcracker Esophagus

Topic
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Snapshot
  • A 72-year-old obese woman presents to her primary care physician with intermittent chest pain and difficulty swallowing liquids and solid foods. Cardiac work up including electrocardiogram, cardiac enzymes, and coronary angiography is normal. She undergoes barium swallow radiography, which was normal. Further testing with esophageal manometry shows 182 mmHg of pressure created by the esophagus during peristalsis.
Introduction
  • Clinical definition
    • high-amplitude but coordinated contraction of the esophagus, also known as hyperperistalsis
    • benign and non-progressive
  • Epidemiology
    • any age but more common in 60-70s
  • Pathogenesis
    • causes are unclear
    • may be related to dysregulated neurotransmitters or nitric oxide levels
  • Associated conditions
    • metabolic syndrome
    • obesity
    • gastroesophageal reflux disease
Presentation
  • Symptoms
    • asymptomatic
    • chest pain (non- exertional) that may radiate to arm, back, neck, or jaw
    • dysphagia to solid and liquid foods
  • Physical exam
    • no specific findings
Studies
  • Diagnostic testing
    • diagnostic approach
      • can be difficult to distinguish from cardiac chest pain and cardiac work up such as electrocardiogram (EKG), stress test, and even coronary angiography is often indicated and normal
    • imaging
      • upper gastrointestinal barium swallow
        • can be normal
        • can have a spiral appearance
    • other studies
      • esophageal manometry
        • diagnostic
        • peristaltic contractions with ≥ 180 mmHg amplitude
      • endoscopy
        • normal
        • used to rule out anatomical causes of dysphagia
Differential
  • Achalasia
    • distinguishing factor
      • increased lower esophageal sphincter function
  • Diffuse esophageal spasm
    • distinguishing factor 
      • normal amplitude but non-peristaltic contractions
  • Angina and acute coronary syndrome
    • distinguishing factors
      • cardiac risk factors
      • ↑ cardiac enzymes
      • ST changes on EKG
Treatment
  • Risk factor modification
    • weight loss
  • First-line
    • calcium channel blockers and nitrates
      • reduce the severity of spasm
    • trazodone antidepressant
      • reduce visceral sensitivity
  • Interventional
    • endoscopic injection of botulinum toxin
    • endoscopic dilatation
    • Heller myotomy
      • indicated for cases refractory to other treatment
      • relaxes the lower esophageal sphincter and myenteric plexus
Complications
  • Food bolus obstruction
 

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