Introduction
The esophagus is an organ that moves food from the mouth to the stomach through muscle contractions. Esophagus anatomically consists of two segments a proximal striated muscle (cervical esophagus) and a distal smooth muscle segment (thoracic and abdominal). Spasms of the esophagus are acute in onset and associated with chest pain that can last a few minutes to hours. Hypertensive peristalsis is a smooth muscle disorder with hypercontraction of muscle. However, whether hypertensive peristalsis is a true disorder or a manometric reading is still debated.
What Is Hypertensive Peristalsis?
Hypertensive peristalsis is also known as the nutcracker esophagus. The term nutcracker esophagus is used to describe the vigor of peristaltic contractions. In this condition, there is high pressure and spasm in the esophagus, which are in coordination. As a result, the food gets stuck due to spasms, and the chest pain is more pronounced than dysphagia. The exact reason for disease occurrence is unclear. However, studies suggest gastroesophageal reflux disease (GERD), nerve disorder, and abnormal response to acetylcholine or esophagus-gastric junction obstruction might be a cause.
What Is the Etiology of Hypertensive Peristalsis?
The disorder is most common among women and Caucasians. The risk of developing the condition increases with age.
What Are the Symptoms of Hypertensive Peristalsis?
Hot and cold liquids, stress, fast eating, and cold drinks may exacerbate peristaltic contractions. The symptoms are
Intermittent dysphagia (difficulty swallowing) for solid and liquid food.
Loss of weight due to inadequate food intake.
Cough.
The sensation of foreign body entrapment in the throat (globus).
Severe chest pain occurs if peristalsis is prolonged. The chest pain is felt in the center of the chest or back and can be confused with a heart attack.
Regurgitation (return of food and liquids back to mouth) of food.
Reflex symptoms (heartburn and acid regurgitation).
Some cases of hypertensive peristalsis are asymptomatic. Individuals with this condition have hypertensive and stiff esophagi. The condition resolves independently, with symptoms present for a few months. But sometimes, symptoms are present for several years and impair quality of life. In addition, such patients experience anxiety and depression.
How to Diagnose Hypertensive Peristalsis?
Physical examination aid in the differential diagnosis.
A barium swallow is a test to detect esophageal spasms. Barium sulfate solution is swallowed, and an X-ray is taken to check for abnormalities as the dye passes through the digestive system. Individuals allergic to barium sulfate are not advised for the test. The test is safe but can cause constipation.
High-frequency ultrasound can detect esophageal motility disorder types by assessing the esophagus's sensory and motor sensations.
Computed tomography (CT) can show thickening of the esophageal wall greater than three millimeters if the individual has hypertensive peristalsis. However, other conditions can also present similar findings in CT.
High-resolution manometry shows normal lower esophageal sphincter pressure and high peristaltic contractions in most wet swallows. Synchronous circular and longitudinal contractions are absent, but the contraction amplitude is greater than two millimeters and is of diagnostic importance. The test is done by inserting a thin tube into the stomach through the nose. The test is pressure sensitive and can measure the pressure and strength of esophageal contractions. The test is diagnostic for hypertensive peristalsis.
Esophagogastroduodenoscopy (EGD) is not a specific test for hypertensive peristalsis but can help eliminate other similar diseases.
Distal contractile integral (DCI) can detect the vigor of contractions. The duration, amplitude, and length of esophageal contractions are measured. The variations are described as Clouse plots. If the mean DCI is greater than 5000, hypertensive peristalses are indicated.
How to Treat Hypertensive Peristalsis?
Dietary restrictions and the inclusion of mashed food are advised.
Oral Nifedipine is given during pain episodes and can help in resting phase esophageal contraction.
Calcium channel blockers (Diltiazem) are the first line of therapy. The medications reduce the amplitude of contractions but are ineffective in treating chest pain.
Nitrates reduce the amplitude of contractions and also help in relieving pain. They are the first line of therapy.
Anticholinergics and muscle relaxants reduce smooth muscle contractions.
Phosphodiesterase inhibitors called Sildenafil are smooth muscle relaxants that can reduce lower esophageal sphincter pressure and uncontrolled contractions.
Botulinum toxin injection above the esophageal sphincter temporarily blocks acetylcholine and relieves symptoms by binding to receptors in the nerve endings. However, the efficacy is transient and reduced with repeated treatment.
Protein pump inhibitors relieve symptoms of acid reflux and improve the symptoms throughout treatment, but the efficacy is inconsistent.
Tricyclic antidepressants are most effective in treating the disease and reducing chest pain. Imipramine is the most commonly used drug.
Cognitive behavior therapy is used in patients that have developed anxiety or depression.
Balloon dilatation of the esophagus is done to relieve symptoms. However, the efficacy is irregular, and the condition may recur. The treatment is provided as an outpatient procedure with the use of anesthesia.
If the condition does not resolve with medication, surgery is advised. The procedure is called myotomy or Heller myotomy. Surgical treatment is the last option, as it can worsen the condition in a few patients. Myotomy helps in reducing the amplitude of contractions but can worsen dysphagia in hypertensive peristalsis. Esophagectomy is advised if other treatments fail. The procedure involves the removal of a part of the affected esophagus.
What Is the Differential Diagnosis for Hypertensive Peristalsis?
The corkscrew esophagus is associated with chest pain occurring with or without food intake. Barium swallow study shows corkscrew appearance.
Gastroesophageal reflux disease is presented with heartburn, cough, and dysphagia. This condition is seen alongside hypertensive peristalsis in the majority of cases. The diagnosis is made using esophageal manometry; there is reduced muscle tone.
Esophageal carcinoma presents with dysphagia, pain, nausea, and vomiting. GI (gastrointestinal) endoscopy reveals a tumor in the esophagus and aid in diagnosis.
Achalasia presents with similar symptoms of dysphagia, regurgitation, and cough. Differentiating feature is the appearance of the bird's beak in barium swallow.
Chagas disease.
What Is the Prognosis for Hypertensive Peristalsis?
Most of the cases are mild and resolve on their own. However, the symptoms are sometimes severe, causing severe pain and dysphagia, thus leading to undernutrition. As a result, the quality of life gets affected, and the individuals may not respond to treatment in extreme conditions.
What Are the Complications of Hypertensive Peristalsis?
Myotomy can cause esophageal perforation. Therefore, physicians must diagnose accurately and provide treatments before resuming oral feeding. Esophagectomy can cause vagal nerve injury.
Conclusion
Hypertensive peristalsis can be a debilitating condition. Due to its similarities with other esophageal motility disorders or systemic diseases, the cases are underreported or misdiagnosed. Correct diagnosis can relieve the patients of debilitating symptoms and improve their quality of life. However, treatment efficacy varies from patient to patient and requires further studies to manage the condition effectively.
