Contrações esofágicas proximais e distais no esôfago em quebra-nozes / Proximal and distal esophageal contractions in nutcracker esophagus

JUSTIFICATIVA E OBJETIVOS: Esôfago em quebra-nozes é diagnosticado quando as contrações peristálticas na parte distal do esôfago têm amplitude acima de 180 mmHg, o que pode causar sintomas, mas também pode ocorrer em pessoas assintomáticas. O objetivo deste estudo foi avaliar a amplitude e a duração da contração esofágica em todo segmento do esôfago onde há predominância de musculatura lisa, comparando o resultado de pacientes com esôfago em quebra-nozes com pessoas com motilidade do esôfago normal. MÉTODO: Com o método manométrico e perfusão contínua estudaram-se as contrações esofágicas a 2, 7, 12 e 17 cm do esfíncter inferior do esôfago em 16 sujeitos (média de idade: 46,7 anos) com amplitude de contração acima de 180 mmHg no registro de motilidade a 2 cm e/ou 7 cm proximal ao esfíncter inferior do esôfago (quebra-nozes), e em 27 sujeitos (média de idade: 38,5 anos) com amplitude de contração, medidas nos mesmos locais, entre 30 e 180 mmHg (controles). Cada sujeito realizou 10 deglutições de 5 mL de água. RESULTADOS: Em todos os locais a amplitude, duração e área sob a curva das contrações foram maiores nos sujeitos com esôfago em quebra-nozes do que nos controles (p < 0,01). O tempo de propagação das contrações peristálticas foi similar entre os dois grupos (p > 0,10). CONCLUSÃO: O aumento da amplitude e duração das contrações esofágicas observadas na parte distal do esôfago do paciente com esôfago em quebra-nozes está presente em todo esôfago onde há predominância da musculatura lisa.

BACKGROUND AND OBJECTIVES: Nutcracker esophagus is a condition seen in subjects with peristaltic distal esophageal contractions amplitude above 180 mmHg. It may be associated with symptoms, but may be found in asymptomatic subjects. Our aim in this investigation was to measure the amplitude and duration of the peristaltic esophageal contraction where the esophagus is composed by smooth muscle, comparing the results of patients with nutcracker esophagus with that of subjects with normal esophageal motility. METHOD: With the manometric method and continuous perfusion we measured the esophageal contractions at 2, 7, 12 and 17 cm from the lower esophageal sphincter in 16 subjects (mean age: 46.7 years) with amplitude of contractions above 180 mmHg at 2 and/or 7 cm from the lower esophageal sphincter (nutcracker), and in 27 subjects (mean age: 38.5 years) with amplitude of contractions from 30 to 180 mmHg at 2 and 7 cm from the lower esophageal sphincter (controls). Each subject performed 10 swallows of a 5 mL bolus of water. RESULTS: In every place where the esophageal motility was measured the amplitude, duration and area under the curve of contractions were higher in subjects with nutcracker esophagus than in controls (p < 0.01). The time between the upstroke of esophageal contractions measured each 5 cm was similar in the two groups (p > 0.10). CONCLUSION: The increase in amplitude and duration of esophageal contraction observed in distal esophageal body of subjects with nutcracker esophagus is seen in all esophageal body where there is smooth muscle.

The Nutcracker Esophagus in a Patient with Dermatomyositis / 대한류마티스학회지

In dermatomyositis, involvement of the skeletal muscles of upper esophagus has been reported in many literatures. However, a number of published reports have suggested that motility disturbances of distal esophagus may also be a cause of dysphagia in dermatomyositis and dysphagia in these cases are mainly caused by crico-pharyngeal obstruction or hypomotility of esophagus. The nutcracker esophagus is the one of common esophageal hypermotility disorders causing dysphagia which is characterized manometrically by high pressure in distal esophagus. Recently, we experienced a patient with dermatomyositis who had complained of dysphagia and was diagnosed as having nutcracker esophagus by mannometry. The association of nutcracker esophagus and dermatomyositis has not been reported in the literature. Moreover, the mechanism of nutcracker esophagus differs with that of esophageal involvement in dermatomyositis. Thereby, we report a patient with dermatomyositis who had nutcracker esophagus in the course of her disease.

Factors involved in the Transition from Achalasia to Nutcracker Esophagus or Diffuse Esophageal Spasm after Intrasphincteric Injection of Botulinum Toxin / 대한소화관운동학회지

BACKGROUND/AIMS: To evaluate the factors which are related to the transition from achalasia to diffuse esophageal spasm (DES) or nutcracker esophagus (NE) after botulinum toxin injection to lower esophageal sphincter (LES). METHODS: This study included the 23 patients with achalasia who received an intrasphincteric injection of botulinum toxin. Stational esophageal manometry, 24-hour ambulatory esophageal manometry with pH monitoring, barium esophagogram and endoscopic ultrasonography were performed before and after treatment. We analyzed the parameters from these studies between the cases that transformed to DES or NE within a week and the cases that do not transit. RESULT: Five patients (21.7%) transformed to DES (1) or NE (4) within a week. There were significant differences in contraction amplitude of esophageal body (median, 31 mmHg vs 23 mmHg, p < 0.05) and maximal diameter of esophageal body (median, 2.6 cm vs 4.4 cm, p < 0.05) between these five patients and the remaining patients. There were no significant differences in sex, LES pressure and thickness of muscle layer between two groups. CONCLUSION: Factors involved in transition to NE or DES after botulinum toxin injection to LES of achalasia appears as high amplitude contractions in body of esophagus and less dilation of esophageal body.

Pathophysiologic mechanisms and clinical characteristics in patients with nutcracker esophagus / 中华消化杂志

Objectives To investigate the pathophysiologic mechanisms and the clinical character- istics and variations of nutcracker esophagus(NE).Methods Clinical data obtained from 22 patients with NE were retrospectively analyzed.Seven followed-up patients had esophageal motility,multi-channel electrogastrography(MEGG),the autonomic nervous system(ANS) and psychology tests and were com- pared to 10 healthy subjects(HS).Results①In NE group,12 patients had reflux symptom(55%),7 patients had chest pain(32%)and 3 patients had dysphagia(13%).There was no statistical difference in mean contraction amplitude(MCA) between patients with reflux symptom and chest pain.②Eight out of the 13 patients with NE who received 24 h pH monitoring were positive reflux,and 4 out of 17 patients had reflux esophagitis in endoscopic examinations.The symptoms were improved in 58%patients(7/12) by regular acid-suppression therapies.③There was no statistical difference beween NE and HS groups in dominant frequency and power of MEGG.However,the percentages of normal rhythm in preprandial and slow wave coupling in pre and postprandial of NE patients were significantly decreased than those in HS.④The ANS function in NE group had no statistical difference compared to those in HS.⑤In follow- up group,no difference was found before and after nitroglycerin sublingually.Four patients had depres- sion.Conclusions The clinical presentations of NE are vary.The symptoms of NE were poorly correla- ted with MCA,but partially correlated with GER,which may represent a special subtype of GERD. Gastric dysmotility and psychological factors might contribute to the pathogenesis of NE.

A Case of Nutcracker Esophagus Associated with Chest Pain and Antidepressant Treatment / 대한소화관운동학회지

Nutcracker esophagus is thought to be a common cause of noncardiac chest pain although has not been clearly established, and the effective treatment is lacking. The usual forms of therapy for noncardiac chest pain by nutcracker esophagus have been directed traditionally toward reducing esophageal hypermotility and muscle tone such as nitrate and calcium channel blocker. However, the results of this treatment in the long term care of patient with esophageal symptoms have been generally disappointing and often unsatisfactory. Recently, psychosomatic aspect of esophageal motility disorder including antidepressant treatment has been accepted in the treatment of noncardiac chest pain. We report a 48 year old female with nutcracker esophagus associated chest pain by ambulatory 24 hour esophageal manometry who failed diagnosis by conventional manometry. The symptoms of chest pain, quality of life, and depression of the patient were improved after antidepressant medication.

A study about the characteristics of NE patients with gastroesophageal reflux / 中国实用内科杂志

Objective To detect the characteristics of NE patients with GERD.Methods All the 36 NE patients were divided into two groups:GERD group(11 patients)and non-GERD group(25 patients).Their clinical features and manometric findings were compaired.Results There were significant differences between the two groups in the parameters of 24 h pH monitoring and LES relaxation rate(P0.05).The difference of DeMeester score had statistical significance.Conclusion To properly diagnose the NE patients with reflux,we should consider not only clinical characteristics but also the result of 24 h pH monitoring and esophageal manometry.

A Case of Nutcracker Esophagus Combined with Hypertensive Lower Esophageal Sphincter

Nutcracker esophagus and hypertensive lower esophageal sphincter (LES) are primary esophageal motility disorders. Nutcracker esophagus have demonstrated distal esophageal contraction amplitude that exceeds the normal range (>160mmHg), without association abnormalities of the esophageal contraction wave, or lower esophageal sphinter relaxation. The criteria for diagnosing hypertensive LES take the mean LES pressure >45mmHg, LES relaxation >75% and normal peristalsis, which is a poorly characterized motility disorder associated with chest pain and dysphagia. We experienced a case of nutcracker esophagus combined with hypertensive LES in a 3-year- old girl who presented with projectile vomiting immediately after eating solid foods. After she had taken barium esophagography and esophageal endoscopy, we suspected she had esophageal motor disorder. Esophageal manometric findings show abnormal high pressure of LES (mean LES pressure, 52.9 mmHg), abnormal high amplitude of lower esophagus more than 320 mmHg, normal esophageal perisaltic movement and normal LES relaxation. After pneumatic dilatation, now she can eat semisolid foods. This case may be the first case of nutcracker esophagus combined with hypertemsive LES in children.