The Hypercontractile (Jackhammer) Esophagus. Do the Numbers Matter?

Abstract

Introduction: Jackhammer Esophagus (JE) is an uncommon hypertensive esophageal motility disorder defined by high resolution manometry (HRM) as at least 1/10 hypercontractile peristaltic contraction. Frequently the first swallow during HRM is the only hypercontractile one. The clinical significance of this is unclear. The aim of this study was to assess differences between subjects with JE who have 1/10 hypercontractile swallow vs. ≥2/10 hypercontractile swallows. Methods: Clinical records of consecutive patients who underwent HRM in 2012 were reviewed. JE was defined according to the 2012 Chicago Classification as ≥1 contraction with Distal Contractile Integral (DCI) of >8,000mmHg-cm-s with normal contractile propagation and distal latency. Patients with distal esophageal spasm or achalasia were excluded. Results: JE was seen in 51/1141 subjects (4.5%) who underwent HRM with a median of 3 (IQR 1.0-6.0) hypercontractile swallows per patient. Mean age was 60 ± 10 years and 43% were male. Fourteen (27%) patients (Group 1) had only 1 swallow with DCI>8,000 and the remaining 37 (73%) had ≥2 swallows with DCI>8,000 (Group 2). There was no significant difference in demographics, symptoms, medication use, treatment for JE, past medical/surgical history, endoscopic or barium esophagram findings between the two groups (Table 1). On HRM, both groups had similar basal and respiratory mean lower esophageal pressure, and integrated relaxation pressure. Twelve (24%) patients had esophagogastric junction outflow obstruction. Patients in group 2 were more likely to have higher max DCI (13,892 vs. 9,422; p<0.001) and multi-peaked contractions (67% vs. 27%; p<0.003).Table 1: Patient Characteristics, History and SymptomsConclusion: JE is an uncommon (˜ 4% of HRM) motility disorder occurring primarily in older women with dysphagia. There is no significant clinical difference between JE patients with single vs. multiple hypercontractile swallows. Different phenotypes of JE could not be distinguished based on the frequency of hypercontractile contractions in this study.