Pathophysiology of chest pain in patients with nutcracker esophagus

OBJECTIVES: Nutcracker esophagus is a manometric pattern that is commonly s een in patients with functional (noncardiac) chest pain. However, this patt ern is often unassociated with pain. Consequently, the pathophysiology of c hest pain in these patients is unclear. METHODS: We prospectively examined the sensory perception and biomechanical properties of the esophagus in 10 patients with chest pain and a nutcracke r esophagus, along with those properties in 12 healthy controls using imped ance planimetry. RESULTS: Stepwise balloon distentions reproduced typical chest pain in 9/10 (90%) patients. The threshold for chest pain was lower (I, < 0.05) in pati ents than in controls (mean +/- SD 43 +/- 5 vs 62 +/- 4 cm H2O) but only 2/ 12 controls experienced pain. The thresholds for first perception and moder ate discomfort were also lower (18 +/- 8 vs 30 +/- 11 cm H2O, p < 0.01 and 28 +/- 9 vs 62 +/- 5 cm H2O, p < 0.001) in patients than in controls, but o nly 3/12 controls experienced moderate discomfort. The esophageal reactivit y to balloon distention was higher in patients than in controls (p < 0.001) . The tension-strain curve shifted to the left in the patient group when co mpared to that in the controls (p < 0.05). CONCLUSIONS: Patients with a nutcracker esophagus demonstrate a hypersensit ive and stiff esophagus, Because balloon distention reproduced their chest pain, visceral hyperalgesia of the esophagus may be relevant to the pathoge nesis of their pain. Balloon distention test may be more useful in the eval uation of patients with functional chest pain and a nutcracker esophagus. < (c)> 2001 by Am. Cell. of Gastroenterology.