[Nutcracker esophagus: clinical evaluation of 97 patients]

Are there any differences between nutcracker esophagus with and without reflux?

"Nutcracker esophagus" (NE) is a primary esophageal motor disorder, first described in patients with noncardiac chest pain. In recent years NE has been associated with gastroesophageal reflux disease (GERD). In this study we compare patients with NE with and without GERD, as defined by pHmetry or endoscopy, with respect to clinical, endoscopic, radiologic, and manometric findings. Fifty-two patients with NE were studied. They were divided in two groups: GERD (17-32.6%) and non-GERD (35-67.4%) patients. Females predominated in both groups, with no significant difference in age (p>0.05). Chest pain was the chief complaint in both groups (p>0.05). Clinical findings in patients with and without reflux included chest pain (52.9% and 51.4%), dysphagia (58.8% and 42.8%), and heartburn (64.7% and 42.8%), followed by regurgitation, dyspepsia, ear, nose, and throat (ENT) complaints, respiratory symptoms, and odynophagia (p>0.05). Erosive esophagitis was found in three patients (5.7%). There were no differences between groups in the findings of barium swallow studies and all manometric findings were similar for both groups (p>0.05). We conclude that there were no differences in patients with NE with or without associated reflux disease. It is important to diagnose reflux properly so patients can be treated adequately.

Esophageal Diverticula: Pathogenesis, Clinical Aspects, and Natural History

It has been gradually accepted that esophageal diverticula result from esophageal motor disorders rather than from primary anatomic abnormalities. Twenty-seven patients with these diverticula were evaluated with respect to pathogenesis, clinical aspects, diagnostic tests, therapy, and natural history for a mean of 27 months of followup. Thirteen diverticula were midesophageal, 11 were situated in the distal third of the esophagus, and 3 were in both regions. Esophageal dysmotility was observed in 85% of patients. Specific esophageal motor disorders were more frequent in association with diverticula of the distal third than in midesophageal diverticula, suggesting that they result from a pulsion mechanism. Traction was the possible mechanism in 27% of midesophageal diverticula. Endoscopic esophagitis was seen in one patient and abnormal acid reflux in 25% of the cases, mainly in patients with distal diverticula. Distal diverticula presented with more severe symptoms than did midesophageal diverticula, and 27% of those required surgical treatment. Patients with midesophageal diverticula seem to have a better prognosis than those with more distal disease.

A Questionnaire Study to Assess Long-Term Outcome in Patients with Abnormal Esophageal Manometry

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, "nutcracker" esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p < or = 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, "nutcracker" esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.