Nutcracker esophagus

• Nutcracker esophagus is a primary esophageal motility disorder characterized by high-amplitude peristaltic contractions
• Also known as hypertensive peristalsis or hypercontractile esophagus
• Key feature: Peristaltic contractions with amplitudes ≥180 mmHg (normal: 30-180 mmHg)
• The contractions remain coordinated (unlike diffuse esophageal spasm)
• It is a benign and non-progressive condition
• More common in women and typically occurs in the 60-70 age group

هو اضطراب في حركية المريء يتميز بانقباضات قوية جداً ولكن منسقة

• The exact cause remains unclear and likely multifactorial
• Proposed mechanisms include:
  • Dysregulation of neurotransmitters (acetylcholine, serotonin)
  • Abnormal nitric oxide (NO) levels → decreased smooth muscle relaxation
  • Heightened visceral sensitivity
  • Psychological factors (stress, anxiety)
• Associated conditions:
  • Metabolic syndrome
  • Obesity
  • Gastroesophageal reflux disease (GERD)

• Chest pain (most common symptom) ألم في الصدر
  • Non-exertional (occurs at rest)
  • Can radiate to arm, back, neck, or jaw
  • May mimic angina → Always rule out cardiac causes first
  • Can be severe and disabling
• Dysphagia صعوبة في البلع
  • To both solids AND liquids
  • Intermittent, not progressive
  • Less common than chest pain
• Many patients are asymptomatic (discovered incidentally)
• Physical examination is typically normal

• Step 1: Rule out cardiac causes
  • Electrocardiogram (ECG)
  • Cardiac enzymes (troponin)
  • Stress test
  • Coronary angiography (if indicated)
• Step 2: Evaluate esophageal structure
  • Upper GI barium swallow:
    • Often normal
    • May show "corkscrew" or spiral appearance
    • Rules out structural abnormalities
  • Upper endoscopy:
    • Usually normal
    • Rules out anatomical causes of dysphagia
• Step 3: Confirm diagnosis
  • Esophageal manometry (Gold standard)
    • Diagnostic criteria: Peristaltic contractions with ≥180 mmHg amplitude
    • Normal coordination of contractions (sequential peristalsis)
    • Normal lower esophageal sphincter (LES) function

General Approach

• Treatment is aimed at symptom relief (not cure)
• Many patients require no treatment (asymptomatic)
• Risk factor modification: weight loss if obese

Medical Management

• First-line medications:
  • Calcium channel blockers (e.g., diltiazem, nifedipine)
    • Reduce smooth muscle contraction
    • Decrease amplitude of contractions
  • Nitrates (e.g., isosorbide dinitrate)
    • Smooth muscle relaxation
    • Can be used sublingually for acute episodes
• Second-line medications:
  • Trazodone (antidepressant)
    • Reduces visceral sensitivity
    • Particularly useful if anxiety component
  • Phosphodiesterase-5 inhibitors (e.g., sildenafil)
  • Proton pump inhibitors (if concurrent GERD)

Interventional Treatment

Reserved for patients with severe, refractory symptoms:

• Botulinum toxin injection
  • Endoscopic injection into esophageal wall
  • Temporary effect (3-6 months)
  • May need repeated injections
• Pneumatic dilation
  • Less effective than in achalasia
  • Risk of perforation
• Peroral endoscopic myotomy (POEM) or Heller myotomy
  • Last resort for severe cases
  • Cuts circular muscle fibers
  • Risk of reflux post-procedure

• Generally benign condition with good prognosis
• Non-progressive - does not worsen over time
• No increased risk of esophageal cancer
• Symptoms may fluctuate or resolve spontaneously
• Quality of life can be significantly affected in symptomatic patients