Pathophysiology of Chest Pain in Patients With Nutcracker Esophagus

Mujica, Victor R.; Mudipalli, Ranjit; Rao, Satish S.C.

doi:10.1111/j.1572-0241.2001.03791.x

Cited by 62 publications

(34 citation statements)

References 27 publications

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“…The existence of diminished compliance, increased muscle thickness, and asynchrony of circular and longitudinal muscle contraction have all been associated with chest pain and heartburn in these patients. 16–19 However, it should be noted that the actual relationship of symptoms with nutcracker esophagus is unclear. As seen in our study, a large proportion of patients with nutcracker esophagus are asymptomatic and the persistence or remittance of symptoms is independent of whether manometric evidence of nutcracker esophagus persists in these patients.…”

Section: Discussionmentioning

confidence: 99%

Long-term Outcomes of Patients With Normal or Minor Motor Function Abnormalities Detected by High-resolution Esophageal Manometry

Ravi

Friesen

Issaka

et al. 2015

Clinical Gastroenterology and Hepatology

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Background & Aims High-resolution manometry (HRM) expands recognition of minor esophageal motor abnormalities, but the clinical significance of these is unclear. We aimed to determine the outcomes of minor esophageal motor abnormalities. Methods We reviewed HRM tracings from individuals who underwent esophageal manometry at Northwestern Memorial Hospital from July 2004 through October 2005, using the Chicago classification (version 2.0). We identified 301 patients with normal findings or minor manometric abnormalities (weak peristalsis, hypertensive peristalsis, frequent failed peristalsis, or rapid contractions with normal latency). Ninety-eight patients participated in a phone survey in which they were asked questions from the impact dysphagia questionnaire (IDQ; mean follow-up period: 6 years 5 months). Results Of 301 the patients assessed, 166 had normal findings from HRM, 82 had weak peristalsis, 34 had hypertensive peristalsis, 17 had frequent failed peristalsis, and 2 had rapid contractions with normal latency. The primary indications for HRM of dysphagia (44%) and gastroesophageal reflux (63%) were unrelated to manometric findings. There were no endoscopic or video-fluoroscopic differences between patients with minor manometric abnormalities. Of 98 patients with follow up, findings from HRM were normal in 63, weak peristalsis was observed in 23, hypertensive peristalsis in 10, and frequent failed peristalsis in 2. No patients underwent surgical myotomy, pneumatic dilation, or botulinum toxin injection. Use of proton-pump inhibitors and rates of fundoplication were similar, regardless of manometric findings. Sixteen patients (16%) had significant dysphagia at follow up; hypertensive peristalsis was the most likely to be symptomatic. Conclusion Patients with normal and minor esophageal motor abnormalities report minimal symptoms and have few medical interventions related to esophageal dysfunction during long-term follow up. Identification of normal and minor motor function is therefore likely a good prognostic indicator.

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Section: Discussionmentioning

confidence: 99%

Long-term Outcomes of Patients With Normal or Minor Motor Function Abnormalities Detected by High-resolution Esophageal Manometry

Ravi

Friesen

Issaka

et al. 2015

Clinical Gastroenterology and Hepatology

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“…In addition, this is in agreement with the results of a recent open-label study, in which 16 patients with nutcracker oesophagus and non-cardiac chest pain failed to show any benefit from acid suppression. 29 The question of whether or not nutcracker oesophagus might be a distinct form of non-cardiac chest pain of oesophageal origin -implying a muscular component in the pain -is worthy of some consideration. Significant symptomatic improvement has been obtained with botulinum injections in a group of patients with spastic oesophageal motor disorders, including nutcracker oesophagus, 30 and diltiazem has also been shown to relieve chest pain, together with a decrease in contraction amplitudes.…”

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confidence: 99%

Nutcracker oesophagus: a double‐blind, placebo‐controlled, cross‐over study of the effects of lansoprazole

Börjesson¹,

Rolny

Mannheimer³

et al. 2003

Aliment Pharmacol Ther

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SUMMARYBackground: Nutcracker oesophagus is characterized by high-amplitude oesophageal contractions. Recent data have shown a high prevalence of gastro-oesophageal acid reflux in patients with nutcracker oesophagus and, in open-label trials, patients seemed to benefit from acid suppression. Therefore, it has been suggested that noncardiac chest pain in patients with nutcracker oesophagus may be related to reflux rather than to the motor abnormality itself. Aims: To investigate the effect of intensive acid-suppressive treatment on chest pain in patients with nutcracker oesophagus. Methods: Nineteen patients with nutcracker oesophagus received lansoprazole or placebo in a double-blind, randomized, cross-over study.

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“…Patients with chest pain and nutcracker esophagus were more likely to experience pain (9/10) than the control (2/12) by stepwise esophageal balloon distensions. 70 When esophageal balloon distension test was performed after excluding GERD and achalasia from 332 NCCP patients, hypersensitivity was found in 71% (128/181) of the remaining patients. 21 When esophageal motility disorders other than achalasia were also ex- In a recent systematic review of published trials regarding effects of antidepressants on non-GERD−related NCCP, 74 6…”

Section: ) Esophageal Visceral Hypersensitivitymentioning

confidence: 97%

Noncardiac Chest Pain: Update on the Diagnosis and Management

Rhee

2015

Korean J Gastroenterol

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Noncardiac chest pain (NCCP) is defined as recurring, angina-like, retrosternal chest pain of noncardiac origin. Although patients with NCCP have excellent long-term prognosis, most suffer persistently from their symptoms. Several pathophysiological mechanisms have been suggested, including gastroesophageal reflux disease (GERD), esophageal motility disorder, esophageal hypersensitivity, and psychological comorbidity. Among them, GERD is the most common cause of NCCP. Therefore, GERD should first be considered as the underlying cause of symptoms in patients with NCCP. Empirical proton pump inhibitor (PPI) treatment with a preferably double dose for more than 2 months could be cost-effective. PPI test can also be used for diagnosis of GERD-related NCCP, but it should be considered for patients with NCCP occurring at least weekly and its duration should be at least 2 weeks. However, upper endoscopy and esophageal pH monitoring are necessary when the diagnosis of GERD is uncertain. Esophageal impedance-pH monitoring could further improve the diagnostic yield. Patients with GERD-related NCCP should preferably be treated with a double dose PPI until symptoms remit (may require more than 2 months of therapy for optimal symptom control), followed by dose tapering to determine the lowest PPI dose that can control symptoms. However, treatment of patients with non-GERD−related NCCP is challenging. An empirical treatment of antidepressants could be considered. If there are specific esophageal motility disorders, smooth muscle relaxants or endoscopic treatment may be considered in selected cases. If none of these traditional treatments is effective, a psychology consultation for cognitive behavioral therapy should be considered. (Korean J Gastroenterol 2015;65:76-84) Key Words: Diagnosis; Gastroesophageal reflux disease; Noncardiac chest pain (NCCP); Therapy CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Pathophysiology of Chest Pain in Patients With Nutcracker Esophagus

Cited by 62 publications

References 27 publications

Long-term Outcomes of Patients With Normal or Minor Motor Function Abnormalities Detected by High-resolution Esophageal Manometry

Long-term Outcomes of Patients With Normal or Minor Motor Function Abnormalities Detected by High-resolution Esophageal Manometry

Nutcracker oesophagus: a double‐blind, placebo‐controlled, cross‐over study of the effects of lansoprazole

Noncardiac Chest Pain: Update on the Diagnosis and Management

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