Clinical Symptom Presentation of Hypercontractile Peristalsis in the Era of High-Resolution Manometry: A Single-Center Experience

Abstract

Background: Hypercontractile motility of the esophagus is occasionally noted on high-resolution manometry (HRM), but its clinical correlations are unclear. We compared symptom severity and clinical presentation of patients with hypercontractile motility of the esophagus. Methods: This was a retrospective cohort study. We queried a prospectively maintained database for patients who underwent esophageal function testing from October 1, 2016, to October 30, 2018. We included patients with jackhammer esophagus (JE; ≥2 swallows with distal contractile integral [DCI] ≥8,000 mm Hg•cm•s), nutcracker esophagus (NE; mean DCI 5,000-8,000 mm Hg•cm•s without meeting JE criteria), or esophagogastric junction outflow obstruction ([EGJOO]: abnormal median integrated relaxation pressure (> 15 mm Hg) without meeting achalasia criteria, with JE [EGJOO-h], or normal motility [EGJOO-n]). HRM, endoscopy, barium esophagram, ambulatory pH studies, and symptom questionnaires were reevaluated for further analysis. Clinical parameters were analyzed using Spearman Rho correlation. Categorical variables were assessed with Fisher exact or chi-square test. Results: Altogether, 85 patients met inclusion criteria. They were divided into 4 subgroups: 28 with JE, 18 with NE, 15 with EG-JOO-h, and 24 with EGJOO-n. Patients with EGJOO-h were the most symptomatic overall. No correlation was seen between symptoms and mean DCI (p ≥ 0.05 all groups) or number of hypercontractile swallows (≥8,000 mm Hg•cm•s, p ≥ 0.05). A significant correlation was noted between dysphagia and lower esophageal sphincter pressure (LESP) and LESP integral (p ≤ 0.05). Conclusion: The number of hypercontractile swallows and mean DCI were not associated with patient-reported symptoms. Elevated LESP may be a more relevant contributor to dysphagia.

Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results—Results from a multicenter French cohort

“…The lack of relationships between manometric data and symptoms, especially chest pain, has also been reported previously. 3,4,9,11 of medical treatment has also been reported by others. 9 The endoscopic treatments seemed to provide better success rates than the medical treatments.…”

“…In some patients, symptoms, mainly chest pain, may occur during HRM; unfortunately, this was not reported in the clinical reports and could not be analyzed in our cohort. The lack of relationships between manometric data and symptoms, especially chest pain, has also been reported previously 3,4,9,11 . In our present study, only single water swallows have been used during HRM.…”

“…The clinical characteristics of JE patients have been poorly reported. Some retrospective cohorts have been reported so far, 2–11 but the number of patients was limited; the most important only included 81 patients 9 . Dysphagia is the most frequent symptom, occurring between 53% and 86% of the patients, associated or not with chest pain or reflux symptoms.…”

How to approach esophagogastric junction outflow obstruction?

“…A study in 39 EGJOO patients comparing 15 patients with combined EGJOO and esophageal hypercontractile peristalsis and 24 patients with only EGJOO found no significant difference in demographic data and symptom severity between both groups. 29 Two-thirds of patients in each group reported at least one moderate to severe symptom that affected their daily life. Another study included 56 patients with EGJOO, 44 patients with hypercontractile esophagus, and 33 healthy volunteers.…”

“…Most of the patients were overweight, with a mean body mass index of 26.5-28.6 kg/m 2 . 16,27,28 Clinical and HRM features of patients with EGJOO Most of the studies reported dysphagia as the most common symptom in EGJOO patients (36-89%), 2,23,24,29,30 followed by retrosternal pain (10-71%) and heartburn and/or regurgitation (8.4-35%). 2,15,[23][24][25][26]30 In a subgroup analysis that included only functional EGJOO, the prevalence of dysphagia decreased to 25-50%.…”