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Relationship between manometric findings and reported symptoms in nutcracker esophagus: insights gained from a review of 313 patients

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Nutcracker esophagus (NE) is a well-described esophageal motility disorder often implicated as the cause of chest pain (CP). The aim of this study was to analyze the role of peristaltic amplitude, lower esophageal sphincter (LES) pressure, and 24 h pH scores in patient symptomatology.


After obtaining Institutional Review Board approval, a retrospective review of manometric data from 1984 to 2008 at the esophageal center was done to identify patients meeting NE criteria (mean distal esophageal body amplitude of >180 mmHg). The data for patient’s symptoms, manometric findings including the amplitude of the distal two esophageal body peristalses, LES pressure, and 24 h pH score were extracted and analyzed.


Out of 4,923 patients, 313 (6.4%) patients met the manometric criteria for NE, and of these, 298 patients had complete manometry data along with at least 1 reported symptom. CP was associated with LES competence, with a significantly higher percentage of patients with high LES pressure complaining of CP (p < 0.05). There was no relationship of with the mean amplitude of esophageal body pressure (p > 0.05) or with distal esophageal acid exposure (p > 0.05).


CP is a commonly reported symptom in patients with manometry findings of NE. However, CP is related to LES competence rather than the amplitude of the esophageal body waves or 24 h pH monitoring scores.

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Esophageal body pressure 8 cm above LES


Esophageal body pressure 3 cm above LES


Chest pain


Hypertensive LES


Incompetent LES


Lower esophageal sphincter


Nutcracker esophagus


Normal LES


Respiratory inversion point


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Correspondence to Sumeet K. Mittal.

Appendix: Standardized questionnaire

Appendix: Standardized questionnaire

  • Heartburn;

    • 0 = No symptom

    • 1 = Minimal: identifiable symptoms, occasional episodes. No prior medical visits

    • 2 = Moderate: primary reason for visit, medical problem

    • 3 = Severe: constant, marked disability in activities of daily living

  • Chest pain;

    • 0 = None

    • 1 = Minimal: occasional episodes

    • 2 = Moderate: reason for visit

    • 3 = Severe: interfering with daily activities

  • Regurgitation;

    • 0 = None

    • 1 = Mild: after straining and/or large meals

    • 2 = Moderate: predictable with position change, straining or lying down

    • 3 = Severe: constant regurgitation, presence of aspiration

  • Lung symptoms (cough/asthma);

    • 0 = None

    • 1 = recurrent cough

    • 2 = night cough

    • 3 = recurrent pneumonia or bronchitis

    • 4 = asthma

    • 5 = change of voice

    • 6 = sinusitis

  • Dysphagia;

    • 0 = None

    • 1 = occasionally with coarse foods (meat, sandwich, hard roll) lasting a few seconds

    • 2 = requires clearing with liquids

    • 3 = Severe: semi-liquid diet, history of meat impaction

    • 4 = For liquids (paradox dysphagia)

  • Odynophagia;

    • 0 = None

    • 1 = yes

  • Epigastric pain;

    • 0 = None

    • 1 = None

    • 2 = Mild

    • 3 = Moderate

    • 4 = Severe

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Tsuboi, K., Mittal, S.K., Legner, A. et al. Relationship between manometric findings and reported symptoms in nutcracker esophagus: insights gained from a review of 313 patients. J Gastroenterol 45, 1033–1038 (2010).

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