The clinical significance of hypercontractile peristalsis: comparison of high-resolution manometric features, demographics, symptom presentation, and response to therapy in patients with Jackhammer esophagus versus Nutcracker esophagus

Abstract

The Chicago Classification version 3.0 (CC v 3.0) defines hypercontractile peristalsis as Jackhammer esophagus (JE); Nutcracker esophagus (NE) is no longer recognized. Data regarding patient characteristics and treatment response for JE versus NE are limited. We aimed to compare demographic characteristics, high resolution manometry (HRM) features, clinical presentation, management strategies, and treatment outcomes in patients with JE versus NE. We performed a retrospective analysis of adult patients diagnosed with NE (CC v 2.0) or JE (CC v 3.0) by HRM from January 2012 to August 2015. Demographics, symptoms, treatments, and response to therapy (none or partial/complete) were ascertained by chart review, for statistical comparisons. In 45 patients with JE and 29 with NE, there was no significant difference in rate of dysphagia (73% and 59%) or chest pain (44% and 59%). Treatment data were available in 29 JE (smooth muscle relaxants in 4, pain modulators in 3, botulinum toxin injection (BTX) in 10, endoscopic dilation in 5, multimodal treatment in 7), and 20 NE patients (smooth muscle relaxants in 2, pain modulators in 2, (BTX) in 6, endoscopic dilation in 3, multimodal treatment in 7). Follow-up data on 26/29 JE and 20/20 NE patients showed similar treatment response (96.4% vs. 82.1%, p= 0.08) after mean follow-up of 11.2 and 11 months, respectively. There were no major differences for JE versus NE in demographics, symptoms, or type of and response to therapy. Larger prospective, controlled trials are needed to clarify the clinical significance and response to treatment in JE and NE.

Clinical features and long‐term outcomes of lower esophageal sphincter‐dependent and lower esophageal sphincter‐independent jackhammer esophagus

“…In our study, we found no significant association between normal range IRP and symptomatic improvement at last clinical ( P = 0.48) or cumulative ( P = 0.86) follow‐up. Other studies have demonstrated no clear relationship between any manometric or clinical parameter and response to a particular treatment . Our findings confirm this in a larger cohort and suggest the need for larger, coordinated studies to better delineate the features which predict need for treatment and selection of treatment modality.…”

“…between any manometric or clinical parameter and response to a particular treatment. 6,7,13,14 Our findings confirm this in a larger cohort and suggest the need for larger, coordinated studies to better delineate the features which predict need for treatment and selection of treatment modality.…”

“…Several recent studies have suggested that symptoms in JHE may remit spontaneously in a substantial proportion of patients and that treatment may not lead to enhanced occurrence or timing of symptomatic resolution. [5][6][7] Interestingly, our study demonstrated that non-pharmacologic treatment (ie, surgical myotomy, POEM, or endoscopic treatment) resulted in a significantly higher rate of symptomatic improvement at last clinical follow-up. However, this effect dissipated with long-term follow-up by phone questionnaire.…”

“…A recent study in 40 patients with JHE followed for a mean of 3 months suggested that these patients may follow a more benign course than previously thought, even in the absence of directed treatment . Furthermore, treatment in JHE is currently heterogeneous and not generally informed by the pattern of contraction …”

“…5 Furthermore, treatment in JHE is currently heterogeneous and not generally informed by the pattern of contraction. [4][5][6] We aimed to evaluate a large cohort of patients with JHE to determine whether including the differential pressure contribution of the LES to defining the presence of JHE predicts distinct clinically relevant features or outcomes on longitudinal follow-up.…”