High-resolution impedance manometry findings in patients with nutcracker esophagus


  • Author Disclosure

  • Masato Hoshino, Abhishek Sundaram, Arpad Juhasz, Fumiaki Yano, Kazuto Tsuboi, Tommy H Lee, Sumeet K. Mittal have no conflicts of interest or financial ties to disclose.

Dr Sumeet K. Mittal, Department of Surgery, Creighton University Medical Center, 601 North 30th Street, Suite 3700, Omaha, NE 68131, USA. Email: SumeetMittal@creighton.edu


Background and Aim:  The objective of this study was to evaluate the association between high-resolution manometry (HRM) and impedance findings and symptoms in patients with nutcracker esophagus (NE).

Methods:  After institutional review board approval retrospective review of a prospectively maintained database identified patients who were diagnosed with NE as per the Chicago classification (distal contractile integral [DCI] > 5000 mmHg-s-cm) at Creighton University between October 2008 and October 2010. Patients with achalasia or a history of previous foregut surgery were excluded. NE patients were sub-divided into: (i) Segmental (mean distal esophageal amplitude [DEA] at 3 and 8 cm above lower esophageal sphincter [LES] < 180 mmHg) (ii) Diffuse (mean DEA at 3 and 8 cm above LES > 180 mmHg) and (iii) Spastic (DCI > 8000 mmHg-s-cm).

Results:  Forty-one patients (segmental: 13, diffuse: 4, spastic: 24) satisfied study criteria. Patients with segmental NE would have been missed by conventional manometry criteria as their DEA < 180 mmHg. A higher percentage of patients with spastic NE (63%) had chest pain when compared to patients with segmental NE (23%) and diffuse NE (25%). There was a significant positive correlation between chest pain severity score and DCI while there was no significant correlation between dysphagia severity and DCI.

Conclusions:  In patients diagnosed with NE using the Chicago classification presence and intensity of chest pain increases with increasing DCI. The present criteria (> 5000 mmHg-s-cm) seems to be too sensitive and has poor symptom correlation. Adjusting the criteria to 8000 mmHg-s-cm is more relevant clinically.