DOES ABNORMAL ESOPHAGEAL FUNCTION OCCUR IN PATIENTS WITH NUTCRACKER ESOPHAGUS?

Abstract

Purpose: Esophageal manometry (EM) is the gold standard for diagnosis of motility abnormalities. Nutcracker esophagus (NE) is defined by mean distal esophageal amplitude (DEA) exceeding 180 mm Hg. Data on the functional (i.e. bolus transit) implications of this finding are limited. Aim: To assess bolus transit in patients with NE using combined multichannel intraluminal impedance and manometry (MII-EM). Methods: In a retrospective review of 558 combined MII-EM tracings recorded at our institution we identified 43 patients (7.7%) with NE and compared their bolus transit patterns to 192 patients (34.4%) with normal esophageal manometry. Patients received 10 liquid (saline) and 10 viscous (apple-sauce like) swallows (5 ml each), 30 second apart. Bolus transit time (time elapsed from bolus entry in the proximal esophagus to bolus exit in the distal esophagus) and overall normal/abnormal bolus transit were recorded. Normal liquid bolus transit was defined as >80% swallows with complete bolus transit and normal viscous bolus transit was defined as >70% swallows with complete bolus transit Results: All but one (42/43; 98%) of patients with NE had complete bolus transit for both liquid and viscous swallows compared to 181/192 (94%) of those with normal manometry. Of the total swallows, 421/430 (97.9%) liquid swallows had complete bolus transit in the NE patients compared to 1792/1917 (93.5%) liquid swallows for normal manometry. The mean bolus transit time in the 43 patients with NE (6.5 ± 0.3 sec) was significantly (p = 0.014) shorter than that for the 192 patients with normal esophageal motility (7.5 ± 0.1 sec). Similarly the mean peristaltic onset velocity in the 43 patients with NE (2.6 ± 0.16 sec) was significantly (p = .04) faster than that for the 192 patients with normal esophageal motility (2.3 ± 0.07 sec). Conclusions: The high contraction amplitudes in patients with nutcracker esophagus are associated with more rapid esophageal transit; confirming the superphysiologic nature of this manometric finding. Nutcracker esophagus is not associated with a functional abnormality.