title: Nutcracker esophagus: demographic, clinical features, and esophageal tests in 115 patients.
abstract: Nutcracker esophagus (NE) is a common esophageal motility disorder chacterized by high amplitude peristaltic contractions in the distal esophagus. While previous studies have examined selected aspects of this condition (e.g. pathogenesis and treatment), there is a paucity of data regarding demographic and clinical features in large cohorts of patients. The aim of this study was to describe demographics, clinical features, comorbidities, time to diagnosis, source of patient referral by specialty, and medication use in a large cohort of patients with NE. We retrospectively analyzed consecutive cases of NE diagnosed from 2008-2010. The electronic medical records of these patients were reviewed, and relevant information was extracted. We identified 115 patients with NE. The median age was 62 years (range 25-87 years), and 63% were female. The median time patients experienced symptoms prior to diagnosis was 24 months (0-480 months). Most patients presented to an internal medicine consultant (42%) or to a gastroenterologist (35%). Presenting symptoms were chest pain (31%) and dysphagia (21%). Gastroesophageal reflux disease (GERD) symptoms were common: heartburn occurred in 51% of patients, 77% had a prior history of GERD, and 78% were receiving acid suppressive medications. GERD was confirmed by testing in at least 35%. Psychiatric comorbidity occurred in 24% with half the patients receiving psychotropic medications. Irritable bowel syndrome (IBS) and fibromyalgia co-existed in 15% and 12% of patients, respectively. Surprisingly, opioids were prescribed to 26% of patients. No statistically significant correlation was found between esophageal motility parameters and symptoms. In this study, NE patients were more commonly middle-aged females experiencing a considerable amount of time between symptom onset and diagnosis. Many were initially evaluated by internists for dysphagia or chest pain and had a history of GERD. Medication prescribed prior to diagnoses frequently involved acid suppression, but narcotic and psychotropic prescriptions were also commonly used. Central sensitization syndromes (fibromyalgia and IBS), psychiatric comorbidity, and reflux commonly coexisted. Our study suggests that future investigations should address the role and interaction of GERD and psychiatric disorders in NE.
authors.affiliation: Medical School, Univerisity of Iowa, Iowa City, Iowa, USA.
authors.forename: R
authors.initials: R
authors.lastname: Lufrano
authors.forename: M G
authors.initials: MG
authors.lastname: Heckman
authors.forename: N
authors.initials: N
authors.lastname: Diehl
authors.forename: K R
authors.initials: KR
authors.lastname: DeVault
authors.forename: S R
authors.initials: SR
authors.lastname: Achem
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000863:Antacids / Q000627:therapeutic use; D002637:Chest Pain / Q000150:complications; D015897:Comorbidity; D003680:Deglutition Disorders / Q000150:complications; D057286:Electronic Health Records; D015154:Esophageal Motility Disorders / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D050782:Esophageal pH Monitoring; D005260:Female; D005356:Fibromyalgia / Q000150:complications; D005764:Gastroesophageal Reflux / Q000150:complications; D005769:Gastrointestinal Motility / Q000502:physiology; D006356:Heartburn / Q000150:complications; D006801:Humans; D043183:Irritable Bowel Syndrome / Q000150:complications; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis; D008875:Middle Aged; D011619:Psychotropic Drugs / Q000627:therapeutic use; D012189:Retrospective Studies; D061665:Time-to-Treatment
chemical_list: D000701:Analgesics, Opioid; D000863:Antacids; D011619:Psychotropic Drugs
keywords: Nutcracker Esophagus; comorbidity; diagnosis; electronic medical record; esophageal motility disorder