Nutcracker Oesophagus

DEFINITION
AKA Hypercontracting oesophagus
Essentials of diagnosis: chest pain, dysphagia, intermittent symptoms, peristaltic waves of high amplitude and long duration.

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EPIDEMIOLOGY
 
Uncommon

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AETIOLOGY

Unknown
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BIOLOGICAL BEHAVIOUR

Complications
Regurgitation and aspiration may occur.
Epiphrenic diverticulum.

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MANIFESTATIONS

Symptoms

Chest pain
Dysphagia (50%)


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INVESTIGATIONS

Imaging
Barium swallow is usually normal.

Manometry
Key test
1. Normal propagation of waves (no simultaneous contractions)
2. High amplitude waves in distal oesophagus (>180 mmHg) and duration (>6s)
3. Normal LES function / relaxation.

pH Monitoring
Essential; GERD can mimic these symptoms secondarily; may change management.

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MANAGEMENT

Reassure non cardiac.

Medical
Ca channel blockers decrease amplitude of contractions but don't improve pain very reliably.
Nitrates, sildenafil, PPIs, tricyclics can be trialled with variable success.

Operative
Surgery is disappointing.  Reserved for very few.
- even less satisfactory than for diffuse oesophageal spasm.
Chest pain persists in 50%, dysphagia in 20%.
- know that the pain does not correlate with the high pressure contractions, so reducing them by myotomy will not help.

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REFERENCES
Doherty
Cameron