Nutcracker esophagus , or peristaltic hypertension , is a disorder of esophageal movement characterized by contraction of smooth esophageal muscle in normal sequence but in excessive or prolonged amplitude. Eesphagus nutcracker is one of several disorders of esophageal motility, including secretia and diffuse esophageal spasms. This causes difficulty in swallowing, or dysphagia, in both solid and liquid foods, and can cause significant chest pain; may also be asymptomatic. The esophagus nutcracker can affect people of all ages, but is more common in the sixth and seventh decades of life. Diagnosis is made by the study of esophageal motility (esophageal manometry), which evaluates esophageal pressure at various points along its length. The term "nutcracker esophagus" derives from the finding of increased pressure during peristaltics, with a diagnosis made when the pressure exceeds 180 mmHg; this has been likened to the pressure of a mechanical nut breaker. This disorder does not develop, and is not associated with complications; as a result, treating the esophagus nutcracker only controls symptoms.
Video Nutcracker esophagus
Symptoms
Eesphagus nutcracker is characterized as an esophageal motility disorder, which means that it is caused by abnormal movement, or peristalsis of the esophagus. Patients with motility disorder present with two main symptoms: either with chest pain (usually reported as non-cardiac chest pain as esophageal origin), usually found in seizure disorders, or with dysphagia (difficulty swallowing). The esophagus nutcracker may present with either of these, but chest pain is a more general presentation. Chest pain is very severe and intense, and mimics heart chest pain. It can spread to the arms and back. The symptoms of the nutcracker's esophagus are intermittent, and can occur with or without food. Rarely, patients may present with sudden esophageal obstruction after eating food (called food bolus obstruction, or 'steakhouse syndrome') requiring urgent care. This disorder does not develop to produce worsening symptoms or complications, unlike other motility disorders (such as intellect) or abnormal anatomic abnormalities (such as peptic stricture or esophageal cancer). Many patients with esophagus nutcracker have no symptoms at all, because esophageal manometric research done in asymptomatic patients can show similar motility findings with esophagus nutcracker. Eesphagus nutcracker can also be associated with metabolic syndrome. The incidence of nutcracker esophagus in all patients is uncertain.
Maps Nutcracker esophagus
Diagnosis
In patients with dysphagia, testing may be first performed to rule out the cause of anatomy of dysphagia, such as an oesophageal anatomic distortion. This usually includes oesophageal visualization with endoscopy, and may also include barium swallowing the esophageal X-rays. Endoscopy is usually normal in patients with esophageal nutcracker; However, abnormalities associated with gastroesophageal reflux disease, or GERD, associated with esophagus nutcracker, can be seen. Ingestion of barium in the esophagus nutcracker is also usually normal, but it can provide a definitive diagnosis if contrast is given in tablet or granule form. Studies on endoscopic ultrasound show a slight tendency toward thickening of the esophageal muscle propolis in the esophagus nutcracker, but this is not useful in making the diagnosis.
Study of esophageal motility
The diagnosis of esophageal nutcracker is usually made by studying the esophageal motility, which shows the characteristic features of the disorder. The study of esophageal motility involves measuring esophageal pressure after a patient takes wet (containing fluid) or dry (solid containing) swallowing. Measurements are usually taken at various points in the esophagus.
The esophagus nutcracker is characterized by a number of criteria described in the literature. The most commonly used criterion is the Castell criterion, named after the American gastroenterologist D.O. Castell. The Castell Criteria included one major criterion: average peristaltic amplitude in the distal throat of more than 180 mm Hg. Minor criterion is the existence of repeated contractions (meaning two or more) that last more than six seconds. Castell also noted that the lower esophageal sphincter relaxes normally in the esophagus nutcracker, but has a higher pressure than 40 mm Hg at baseline.
Three other criteria for the definition of the nutritor's esophagus have been defined. The Gothenburg criteria consist of a peristaltic contraction, with an amplitude of 180 mm Hg at each place in the esophagus. The Richter Criteria involves a peristaltic contraction with an amplitude greater than 180 mmHg from the average 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. The Achem criterion is stricter, and is an extension of the study of 93 patients used by Richter and Castell in their development criteria, and requires amplitude greater than 199 mmHg at 3 cm above the lower esophageal sphincter (LES), greater than 172 mm Hg on 8 cm above LES, or greater than 102 mm Hg at 13 cm above LES.
Pathophysiology
The esophageal pathology specimens in patients with esophageal nutcracker do not show significant abnormalities, unlike patients with intellect, where Auerbach plexus damage is seen. Pathophysiology of the esophagus nutcracker may be associated with abnormalities in neurotransmitters or other mediators in the distal throat. Abnormalities of nitric oxide levels, which have been seen in the secretasia, are postulated as a primary disorder. Because GERD is associated with esophagus nutcracker, changes in nitric oxide and other chemicals released may be in response to reflux.
Treatment
The esophagus nutcracker is a benign and non-progressive condition, which means it is not associated with significant complications. Patients are usually reassured by their doctors that the disease is unlikely to deteriorate. However, the symptoms of chest pain and dysphagia may be severe enough to require treatment with medication, and rarely, surgery.
The first step of care focuses on reducing risk factors. While weight reduction may be useful in relieving symptoms, the role of acid suppression therapy to reduce esophageal reflux remains uncertain. Very cold and very hot drinks can trigger esophageal spasm.
Medical therapy for esophageal nutcrackers includes the use of calcium-channel blockers, which relaxes the lower esophageal sphincter (LES) and alleviate the symptoms of dysphagia. Diltiazem, a calcium channel blocker, has been used in randomized control studies with good effect. Nitrate drugs, including isosorbide dinitrate, administered before meals, may also help relax LES and improve symptoms. Cheap generic combinations of belladonna and phenobarbital (Donnatal and other brands) can be taken three times a day as tablets to prevent attacks or, for patients with only occasional episodes, as a panacea at the onset of symptoms. Phosphodiesterase inhibitors, such as sildenafil, may be given to relieve symptoms, especially pain, but small trials have not been able to show clinical improvement. Finally, trazodone, an antidepressant that reduces visceral sensitivity, has also been shown to reduce the symptoms of chest pain in patients with esophagus nutcracker.
Endoscopic therapy with botulinum toxin, also known as Botox, can also be used to correct dysphagia that stabilizes unintentional weight loss, but its effect has limited effects on other symptoms, including pain, while also being a temporary treatment that lasts several weeks. Finally, pneumatic esophageal dilatation, which is an endoscopic technique in which high pressure balloons are used to stretch the LES muscles, can be done to improve symptoms, but again no clinical improvement is seen in terms of motility.
Surgery
In patients who have no response to medical therapy or endoscopy, surgery can be performed. A Heller myotomy involves an incision to disrupt the LES and myenteric plexus that is in its control. Heller myotomy is used as a final treatment option in patients who do not respond to other therapies.
See also
- esophageal spasms
References
Further reading
- Freidin N., Traube M., Mittal R.K.; et al. (1989). "Lower esophageal sphincter of hypertension". Digest Dis Sci . 34 : 1063-1067. doi: 10.1007/BF01536375. CS1 maint: The explicit use of et al. (link) CS1 maint: Many names: list of authors (links)
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