From the Guidelines
The nutcracker phenomenon refers to a condition where the esophagus experiences abnormally strong contractions, often accompanied by dysphagia and squeezing retrosternal pain or spasm, as described in the context of esophageal motility disorders 1. This condition is part of a broader category of esophageal motility disorders, which also includes achalasia and distal esophageal spasm.
- The symptoms of nutcracker esophagus can mimic those of myocardial ischemia, presenting as squeezing or burning chest pain that may last from minutes to hours.
- The pain often occurs after meals or at night and can worsen with stress, similar to gastroesophageal reflux disease (GERD), which is the most common cause of recurring unexplained chest pain of esophageal origin 1.
- Diagnosis and treatment of nutcracker esophagus would depend on the severity of symptoms and may involve a combination of medical management, lifestyle modifications, and in some cases, procedural interventions to alleviate symptoms and improve quality of life.
- It's essential to differentiate nutcracker esophagus from other causes of chest pain, including cardiac and gastrointestinal conditions, to provide appropriate management and reduce morbidity and mortality associated with misdiagnosis or delayed diagnosis 1.
From the Research
Definition and Characteristics
- The nutcracker esophagus is a commonly diagnosed esophageal motility disorder characterized by high-amplitude peristaltic contractions, often of prolonged duration, in the distal two thirds of the esophagus 2, 3.
- This disorder is typically manifested by symptoms such as dysphagia and chest pain, often described as "angina-like" or noncardiac chest pain 2, 4.
Diagnosis and Testing
- The diagnosis of nutcracker esophagus is often made using manometry, which measures the contractile pressure amplitude in the esophagus 2, 5.
- Radionuclide esophageal scintigraphy (RES) has also been used to diagnose nutcracker esophagus, and has been shown to confirm a functional disorder in a subgroup of patients with the manometric diagnosis 5.
- Esophageal wall blood perfusion (EWBP) has been measured in patients with nutcracker esophagus, and has been found to be significantly lower than in normal subjects 4.
Clinical Features and Comorbidities
- Patients with nutcracker esophagus often experience a considerable amount of time between symptom onset and diagnosis, with a median time of 24 months 6.
- Gastroesophageal reflux disease (GERD) symptoms are common in patients with nutcracker esophagus, and many patients have a prior history of GERD or are receiving acid suppressive medications 6.
- Psychiatric comorbidity, irritable bowel syndrome (IBS), and fibromyalgia are also common in patients with nutcracker esophagus, and may contribute to the development of symptoms 6.
Treatment and Management
- Symptomatic control of nutcracker esophagus is often achieved with medical management, although some patients may require surgical treatment, such as extended esophagomyotomy 2.
- The role of GERD and psychiatric disorders in the development and management of nutcracker esophagus requires further investigation 6.