An Uncommon Cause of Food Impaction

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Purpose: Esophageal food impaction is usually secondary to structural abnormalities of the esophagus such as Schatzki's ring, eosinophilic esophagitis or strictures. Nutcracker esophagus (NE) is an esophageal motility disorder characterized by the presence of hypertensive but peristaltic contraction waves, making food impactions rare. We describe a patient with meat impaction associated with NE. A 66-year-old male presented with chest pain and dysphagia 3 hours after ingesting a large meal. His pain was located in the mid chest associated with difficulty swallowing his own saliva. He denied any history of dysphagia, chest pain or heartburn. Physical exam revealed an alert man in mild distress with pooling of saliva in his mouth. Cardiac, pulmonary and abdominal exams were unremarkable. An EKG and three sets of cardiac enzymes ruled out cardiac causes of chest pain. All the initial laboratory results were normal except for a WBC 11,950; with a normal eosinophil count. A CT of the chest revealed foreign material in the esophagus, consistent with undigested food. Prior to endoscopic evaluation, the patient's symptoms spontaneously subsided. Endoscopy revealed mildly hemorrhagic mucosa in the mid esophagus with no strictures, concentric rings or esophageal furrows. Biopsies of the esophagus were normal, with no evidence of eosinophilic esophagitis. A single contrast esophagram revealed tertiary contractions of the esophagus. High resolution manometry (HRM) (Figure 1) revealed normal peristaltic wet swallows with normal contraction amplitudes at 7 and 11 cm above the LES. At 3 cm above the LES, however, the amplitudes ranged from 196-386 mmHg, consistent with NE. The patient was discharged the day after the procedure and returded 1 month later for follow-up. He remained asymptomatic and no treatment was required. Nutcracker esophagus can be diffuse or segmental. The manometry findings in our patient were consistent with a segmental nutcracker esophagus. Only 4 cases have reported of nutcracker esophagus and food impaction, but ours is the first one diagnosed with high resolution manometry. Although rare, nutcracker esophagus can cause esophageal food impaction and HRM is of paramount importance in diagnosing this entity in minimally symptomatic patients.Figure: [573] High resolution manometry showing hypertensive peristaltic waves in the distal esophagus.