The Nutcracker Esophagus: A Late Diagnostic Yield Notwithstanding Chest Pain and Dysphagia Gabrio Bassotti, MD, PhD, FACG, Serafina Fiorella, MD, Ugo Germani, MD, Paola Roselli, MD, Edda Battaglia, MD, and Antonio Morelli, MD Gastrointestinal Motility Laboratory, GI and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia School of Medicine, Perugia, Italy Abstract. The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagno- sis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esopha- gus could also involve the entire viscus. Fifty-four sub- jects (age range 23–78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21–67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 ± 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dys- phagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was sig- nificantly higher in the patients’ group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Not- withstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esopha- geal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body. Key words: Esophageal motility — Chest pain — Dysphagia — Manometry — Nutcracker esophagus — Deglutition — Deglutition disorders. It has been about 20 years since the association between noncardiac chest pain and high-amplitude peristaltic con- tractions, the so-called nutcracker esophagus has been recognized [1,2]. Since then, it has become evident that approximately 20% of patients admitted to cardiac care units because of chest pain show no abnormalities in a detailed cardiological work-up [3] and that in a certain percentage of these patients the esophagus may be re- sponsible for chest pain [4,5]. In such patients, conventional manometric testing may reveal a substantial amount of esophageal motor abnormalities in those patients with noncardiac chest pain, dysphagia, or both [6], provided an extensive car- diological evaluation had been previously carried out. However, notwithstanding the recent introduction of si- multaneous ambulatory measurements of esophageal motility and pH monitoring, the overall diagnostic yield for noncardiac chest pain is about 50% [7–11], leading to the concept of irritable esophagus (pain of esophageal origin produced by various mechanisms including acid sensitivity and spasm, either spontaneous or in response to provocative testing) [12,13]. The most common esophageal motor abnormality reported in patients with noncardiac chest pain is the nutcracker esophagus [14], frequently indicated as a culprit [15–18], although some authors do not consider it an autonomous entity [19,20]. The identification of the esophagus as the likely source of chest pain may be an important factor in improving Correspondence to: Gabrio Bassotti, M.D., Ph.D., Laboratorio di Mo- tilita ` Intestinale, Clinica di Gastroenterologia ed Epatologia, Policlinico Monteluce, I-06100 Perugia, Italy Dysphagia 13:213–217 (1998) © Springer-Verlag New York Inc. 1998