What are the causes of hypertensive peristalsis?

Causes of Hypertensive Peristalsis

Hypertensive peristalsis in the esophagus is primarily associated with esophageal motility disorders, with the most common being nutcracker esophagus and hypertensive lower esophageal sphincter (LES). 1

Esophageal Causes

Hypertensive Lower Esophageal Sphincter (HLES)

• Defined as a lower esophageal sphincter pressure ≥30-40 mmHg with normal LES relaxation and normal esophageal peristalsis 2, 3
• Often presents with symptoms that mimic various upper gastrointestinal disorders including:
  • Gastroesophageal reflux disease (33% of cases)
  • Dysphagia (18.5%)
  • Non-cardiac chest pain (15%)
  • Epigastric discomfort (11%)
  • Globus sensation (7.5%) 3

Nutcracker Esophagus

• Characterized by high-amplitude peristaltic contractions in the distal esophagus (mean distal amplitude >216 mmHg) 1
• Often coexists with hypertensive LES (approximately 47% of patients with hypertensive LES also have nutcracker esophagus) 1
• Presents primarily with chest pain and dysphagia 1

Paradoxical Association with GERD

• Despite seeming paradoxical, approximately 20-23% of patients with hypertensive LES also have abnormal gastroesophageal reflux 3, 4
• Reflux tends to be mild in these patients but can be clinically significant 4
• Incomplete LES relaxation in response to swallowing may be present in about half of these patients 4

Systemic Causes Contributing to Esophageal Hypertensive Peristalsis

Cardiovascular Conditions

• Hypertension can affect vascular smooth muscle throughout the body, potentially contributing to abnormal esophageal motility 5
• Cardiovascular abnormalities are among the most common causes of systemic issues that can affect various organ systems 5

Neurological Factors

• Autonomic nervous system dysfunction can lead to abnormal peristaltic activity 5
• Increased sympathetic nervous system activity, as seen in conditions like obstructive sleep apnea, can affect smooth muscle function throughout the body 6

Endocrine and Metabolic Disorders

• Thyroid and parathyroid diseases can affect smooth muscle function and contribute to motility disorders 5
• Cushing syndrome and other glucocorticoid excess states can cause vascular and smooth muscle abnormalities 5

Psychological Factors

• Psychological abnormalities, particularly anxiety and somatization, are present in approximately 75% of patients with hypertensive LES 1
• These psychological factors may contribute to symptom reporting and perception 1

Diagnostic Considerations

• Esophageal manometry is the gold standard for diagnosis of hypertensive peristalsis 3
• Contrast studies are often normal, with less than 22% demonstrating abnormalities 3
• Ambulatory pH monitoring should be considered in patients with hypertensive LES who present with heartburn or chest pain to evaluate for GERD 4

Treatment Implications

• Pharmacological treatments often do not change the underlying manometric findings 3
• Surgical interventions such as esophagomyotomy can normalize manometry in selected cases 3
• Patients with coexisting GERD often respond to antireflux treatment, including fundoplication in severe cases 4
• Treatment should target the underlying cause when identified, rather than just the manometric finding 1, 3

Clinical Significance

• Hypertensive peristalsis is often a heterogeneous disorder with varying clinical presentations 1
• Despite abnormal LES parameters, most patients have normal esophageal function 1
• The condition may be part of a spectrum of esophageal motility disorders rather than a distinct pathological entity 2