Nutcracker esophagus

Introduction of nutcracker esophagus Nutcrackeresophagus (NE) is the most common abnormality of esophageal pressure in non-cardiacchestpain. The nutcracker esophagus is characterized by angina pectoris-like chest pain and dysphagia. The clinical manifestations are similar to diffuse esophageal fistula. The intensity of pain, frequency and location of the attack vary from person to person. Chest pain is the main clinical symptom of the nutcracker esophagus. About 90% of patients have chest pain symptoms, often associated with fatigue. basic knowledge The proportion of illness: 0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: lower back pain

Nutcracker esophagus

Cause of the disease (30%)

The cause of the nutcracker esophagus is unknown, and it is considered to be part of the development of primary esophageal dyskinesia. It is likely to be a precursor to diffuse esophageal fistula.

Pathogenesis (30%)

The pathogenesis of this disease is unknown. The study found that most of these patients have a positive reaction to the acid drop test and the acetylcholine drug-induced test, suggesting a high sensitivity to acid and a progressive esophageal denervation mechanism, possibly in the pathogenesis. It has a certain effect, but so far there is no sufficient evidence to prove that the disease is a neurogenic esophageal dyskinesia. Stein et al (1993) reported a group of walnut-shaped esophagus diagnosed by standard esophageal manometry, the symptoms and pressure characteristics of 24h esophageal manometry There is no difference in the performance of diffuse esophageal fistula. Narducci et al (1985) reported that a patient with a nutcracker esophagus was converted into a typical diffuse esophageal fistula at the 1-year follow-up, and Cole et al (1986) treated 13 patients with a nutcracker esophagus. After the basic manometry, a standard acid perfusion test was given. Eight patients (52%) induced chest pain during acid perfusion, but no significant dysmotility, followed by intravenous injection of carbamoyl bromide in 12 patients. In 0.08 mg/kg, 6 patients (50%) induced chest pain, and 7 patients (55%) underwent esophageal motion analysis with diffuse esophageal spasm.

Blackwell (1984) speculated that the disease will eventually develop into achalasia, which is thought to be related to the response to acid reflux, and related to mental and psychological factors and pain threshold. Mental and psychological factors can induce chest pain symptoms. Patients are often accompanied by depression, anxiety and other manifestations. At the same time, changes in esophageal dynamics are also related to mental stimulation, but no clear pathological changes have been found. Walnut-grafted esophagus and diffuse esophageal fistula, achalasia and The relationship between gastroesophageal reflux is worthy of further study, and Blackwell (1984) suggests that the following transformational relationships may exist between them (Figure 1).

Nutcracker esophagus prevention

Do not eat old-fashioned or irritating things; promote fresh fruits and vegetables with more vitamin C; choose light, digestible foods, keep the stool smooth; drink yogurt, mushroom soup, seaweed soup, yellow fish soup. Eat less food, stimulate food such as eating less beef and mutton, dog meat, chicken, fish and shrimp and other foods, do not eat fried and smoked food, do not eat heavy food. Avoid smoking, alcohol, and not eating spicy, rough food.

Nutcracker esophagus complications Complications, lower back pain

Can be accompanied by back pain.

Nutcracker esophageal symptoms Common symptoms Dysphagia, angina, esophagus, heartburn, anxiety, cardiogenic chest pain, esophageal fibrosis, depression

The nutcracker esophagus is characterized by angina pectoris-like chest pain and dysphagia. The clinical manifestations are similar to diffuse esophageal fistula. The intensity of pain, frequency and location of the attack vary from person to person.

1. Chest pain: It is the main clinical symptom of the nutcracker esophagus. About 90% of the patients have chest pain symptoms, which are often related to fatigue. The typical manifestations are chronic chest pain, recurrent or intermittent episodes, often located behind the sternum or under the xiphoid. More severe, squeezing pain, acidic food or depression, anxiety, emotional and other mental or psychological factors can induce chest pain, may also be associated with back pain, chest pain is similar to angina, but the patient's coronary angiography More no abnormal findings.

Chest pain is due to increased amplitude and/or prolonged contraction of esophageal peristaltic contraction, and the incidence is higher than diffuse esophageal fistula or achalasia. Stein et al (1993) reported the incidence of chest pain in 33 patients with nutcracker esophagus. There were 22 cases (67%), 10 cases (30%) with non-obstructive dysphagia, and 1 case (3%) with heartburn.

2. Dysphagia: About 70% of patients with walnuts in the esophagus, dysphagia is often associated with the onset of chest pain, with nitroglycerin preparations, calcium channel blockers can ease it.

3. Heartburn: associated with increased gastroesophageal reflux and increased sensitivity of the esophageal mucosa, gastric acid reflux may play an important role in the development of symptoms.

Nutcracker esophagus examination

1. Esophageal manometry: The esophageal pressure measurement of the nutcracker esophagus is characterized by high amplitude peristaltic contraction with prolonged contraction time, such as chest pain episodes, esophageal peristaltic contraction, but the average longitudinal contraction amplitude of the lower segment is more than 16 kPa (120 mmHg). Or the peak value exceeds 26.7kPa (200mmHg), or the time exceeds 7s, the diagnosis can be confirmed. The anesthesia pressure record of the nutcracker esophagus can be normal during the asymptomatic period. These patients can use the Tengxilong stimulation test to judge whether the chest pain is abnormal with the esophagus. related.

The diagnostic criteria proposed by Benjamin et al. (1979) are:

(1) High amplitude contraction of the lower esophagus (10 swallows), the average amplitude of the contraction exceeds or equals 16 kPa (120 mmHg).

(2) The peak contraction is at least 1 time (10 swallows), and its amplitude exceeds 26.6 kPa (200 mmHg).

(3) The duration of the contraction wave is mostly extended.

(4) Conductive peristalsis after swallowing.

2. Esophageal X-ray barium angiography: Esophageal X-ray barium angiography of the nutcracker esophagus can be normal or suggestive of non-specific esophageal motor dysfunction, lack of specificity for the diagnosis of the nutcracker esophagus, but excluding esophageal physique and other functions Sexual abnormal pathological changes are of great significance. Ott (1986) performed X-ray esophagography on 20 patients with walnuts and esophagus. Eight patients had moderate to severe third contraction wave, and the average thickness of esophagus was 2.64 mm (1.5-4.0 mm, control group). It was 2.55mm, 2~3.5mm); 16 cases of esophageal peristalsis were normal. Chobanian et al. (1986) performed radiography and esophagography on 22 cases of nutcracker esophagus. Only 8 cases (36%) had abnormal esophageal movement. Chronic esophageal fistula or third contraction wave, 12 cases (55%) images were normal.

3. Tensilon irritating test: After the patient was given intravenous Tengxilong, the chest pain and abnormal esophageal pressure were positive.

4. Standard acid perfusion test: patients with standard acid perfusion of esophagus, patients with chest pain or abnormal esophageal pressure were positive, Cole et al (1986) reported standard acid perfusion test, 62% of patients induced chest pain, but no significant abnormalities in esophageal motility.

Diagnosis and identification of nutcracker esophagus

Diagnostic criteria

The symptoms of chest pain caused by nutcracker esophagus are similar to angina pectoris, and the drugs for treating angina pectoris can effectively alleviate it, making the diagnosis difficult to make. Some authors report that patients with clinical diagnosis of angina pectoris continue to have chest pain despite coronary artery bypass grafting. After 24 hours of esophageal pH monitoring and esophageal manometry, the diagnosis was confirmed. The following conditions can be considered:

1. Chronic, recurrent or intermittent episodes of severe chest pain, routine cardiovascular examination and coronary angiography to exclude cardiogenic chest pain.

2. With or without dysphagia.

3. Esophageal manometry shows a high amplitude peristaltic contraction of the esophagus and a prolonged duration.

4. Esophageal endoscopy and imaging examination showed no abnormalities in esophageal structure.

5. Acid perfusion or Tengxilong stimulation test positive.

Differential diagnosis

It should be differentiated from achalasia, diffuse esophageal fistula, gastroesophageal reflux disease and esophageal neurosis. The identification is mainly based on esophageal manometry.

Diffuse esophageal fistula

The nutcracker esophagus and diffuse esophageal fistula belong to the primary esophageal dyskinesia disease, and it is reported that this disease is a precursor to diffuse esophageal fistula. It is difficult to identify it. Benjamin et al. (1979) found that the disease has high amplitude contraction. More in the lower part of the esophagus, accompanied by normal primary esophageal peristalsis.

2. Gastroesophageal reflux

Patients with gastroesophageal reflux sometimes have abnormal esophageal motility, which is characterized by pseudo-nutrculosis esophageal appearance. Achen et al. (1993) reported 40 (10%) of the nutcracker esophagus from 402 patients with non-cardiac chest pain. The patient, gastroscope confirmed that there were 1 case (2.5%) of erosive esophagitis in 40 cases of peony esophagus; 20 cases of 24 hours of esophageal pH monitoring, 13 cases (65%) had abnormal amount of acid reflux, pressure measurement Check 12 patients (30%) for gastroesophageal reflux in patients with nutcracker esophagus. After 12 weeks of active anti-acid treatment with high doses of ranitidine or omeprazole, 7 patients were treated with high doses of ranitidine or omeprazole. (64%) patients with the characteristics of the nutcracker esophagus disappeared, 2 cases (33%) esophageal motility is normal, it is considered that the abnormal esophageal motility seen in these patients is attributed to gastroesophageal reflux, advocated in the treatment of non-heart Gastroesophageal reflux disease should be ruled out before the source of chest pain.

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