Nutcracker esophagus
Nutcracker esophagus | |
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Other names | Jackhammer esophagus, hypercontractile peristalsis, nutcracker achalasia |
Normal peristalsis in time space graph. Nutcracker esophagus shows higher amplitude contractions (Z-axis) that take longer to pass (X-axis) | |
Specialty | Gastroenterology |
Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the
The diagnosis is made by an esophageal motility study (esophageal manometry), which evaluates the pressure of the esophagus at various points along its length. The term "nutcracker esophagus" comes from the finding of increased pressures during peristalsis, with a diagnosis made when pressures exceed 180 mmHg; this has been likened to the pressure of a mechanical nutcracker. The disorder does not progress, and is not associated with any complications; as a result, treatment of nutcracker esophagus targets control of symptoms only.[1][2]
Signs and symptoms
Nutcracker esophagus is characterized as a
Pathophysiology
Pathology specimens of the esophagus in patients with nutcracker esophagus show no significant abnormality, unlike patients with
Diagnosis
In patients who have dysphagia, testing may first be done to exclude an anatomical cause of dysphagia, such as distortion of the anatomy of the esophagus. This usually includes visualization of the esophagus with an
Esophageal motility studies
The diagnosis of nutcracker esophagus is typically made with an esophageal motility study, which shows characteristic features of the disorder. Esophageal motility studies involve pressure measurements of the esophagus after a patient takes a wet (fluid-containing) or dry (solid-containing) swallow. Measurements are usually taken at various points in the esophagus.[12]
Nutcracker esophagus is characterized by a number of criteria described in the literature. The most commonly used criteria are the Castell criteria, named after American gastroenterologist D.O. Castell. The Castell criteria include one major criterion: a mean peristaltic amplitude in the distal esophagus of more than 180 mm Hg. The minor criterion is the presence of repetitive contractions (meaning two or more) that are greater than six seconds in duration. Castell also noted that the
Three other criteria for the definition of the nutcracker esophagus have been defined. The Gothenburg criterion consists of the presence of peristaltic contractions, with an amplitude of 180 mm Hg at any place in the esophagus.[10][9] The Richter criterion involves the presence of peristaltic contractions with an amplitude of greater than 180 mm Hg from an average of measurements taken 3 and 8 cm above the lower esophageal sphincter. It has been incorporated into a number of clinical guidelines for the evaluation of dysphagia.[9] The Achem criteria are more stringent, and are an extension of the study of 93 patients used by Richter and Castell in the development of their criteria, and require amplitudes of greater than 199 mm Hg at 3 cm above the lower esophageal sphincter (LES), greater than 172 mm Hg at 8 cm above the LES, or greater than 102 mm Hg at 13 cm above the LES.[9][14]
Treatment
People are usually reassured that the disease is unlikely to worsen. However, the symptoms of chest pain and trouble swallowing may be severe enough to require treatment with medications, and rarely, surgery.
The initial step of treatment focuses on reducing risk factors. While weight reduction may be useful in reducing symptoms, the role of acid suppression therapy to reduce esophageal reflux is still uncertain.[15] Very cold and very hot beverages may trigger esophageal spasms.[16][17]
Medications
Medications for nutcracker esophagus includes the use of
Procedures
Endoscopic therapy with botulinum toxin can also be used to improve dysphagia which stabilizes unintentional weight loss, but the effect has limited effect on other symptoms, including pain, while also being a temporary treatment lasting a few weeks.[20] Finally, pneumatic dilatation of the esophagus, which is an endoscopic technique where a high-pressure balloon is used to stretch the muscles of the LES, can be performed to improve symptoms, but again no clinical improvement is seen in regards to motility.[21]
In people who have no response to medical or endoscopic therapy, surgery can be performed. A Heller myotomy involves an incision to disrupt the LES and the myenteric plexus that innervates it. The Heller myotomy is used as a final treatment option in patients who do not respond to other therapies.[22]
Prognosis
Nutcracker esophagus is a benign, nonprogressive condition, meaning it is not associated with significant complications.
See also
References
- ^ Esophageal Spasm at eMedicine
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- ^ "Heartburn or Heart Attack? How to Tell the Difference". health.com. Retrieved 17 April 2018.
- ^ "Esophageal spasms - Symptoms and causes". mayoclinic.org. Retrieved 17 April 2018.
- ^ Schmeck, Harold M. Jr. (19 January 1989). "HEALTH: SYMPTOMS AND DIAGNOSIS; When Chest Pains Have Nothing to Do With a Heart Attack". The New York Times. Retrieved 17 April 2018.
- ^ "Heart Attack and Conditions That Mimic Heart Attack: Learn About Chest Pain". www.secondscount.org. 30 November 2008. Retrieved 17 April 2018.
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- ^ "Esophageal spasm: MedlinePlus Medical Encyclopedia". Nlm.nih.gov. Retrieved 2013-01-15.
- ^ "Esophageal Spasm Causes, Symptoms, Treatments, and More". Webmd.com. 2011-06-01. Retrieved 2013-01-15.
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- ^ "Sildenafil in Esophageal Motility Disorders".
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- ^ "Is there any objective benefit from therapeutic dilatation in patients with nutcracker esophagus ?".
- ^ "Achalasia". The Lecturio Medical Concept Library. 14 October 2020. Retrieved 26 June 2021.