Ask Dr. H: 'Nutcracker esophagus' tough to treat

Question:

A friend of ours was told he has a "nutcracker esophagus." What does that mean?

Answer:

A nutcracker esophagus is one of several esophageal disorders in which the orderly muscular contractions that move a bolus of food from the upper esophagus into the stomach don't occur normally.

Nutcracker

is a good visual description of what's going on. While there may be periods when everything's normal, at least one-third of the contractions in the lower esophagus of people with this condition occur with a force so strong that some observers have described them as powerful enough to crack open a walnut. I'm not sure about that, but the contractions are two to four times normal strength. These powerful contractions can last longer than eight seconds.

Symptoms of the disorder are what you might expect: pain when swallowing food; a sensation that food won't go down; regurgitation; and chest pain from forceful contractions. Since the esophagus is in the center of the chest, an event of nutcracker esophagus might cause someone to think he's having a heart attack. (All chest pain should be taken seriously; never dismiss such pain as being noncardiac until it is proved otherwise. It is possible to have both a nutcracker esophagus and heart disease.)

The best way to diagnose a nutcracker esophagus is to measure the force of the muscular contractions using special instrumentation. An acid test is sometimes used to provoke irritation; the esophageal muscle response is then monitored.

The treatments aren't great. Some get relief with long- or short-acting nitroglycerin - the same drug given for relief of angina or during a heart attack. That can also make this chest pain tough to sort out. The muscles that line the esophagus wall depend on calcium bridges that allow one fiber to contract with another.

Blood pressure medications in the class known as calcium channel blockers (Verapamil, Norvasc, Cardizem) help modestly by relaxing esophageal muscle tone. Some have tried botulinum (Botox) toxin injections to weaken the muscles, but there are concerns about that. Others have found success with periodic esophageal stretching and dilation. As a final treatment option, what is known as Heller myotomy surgery cuts through the muscle fibers and nerves of the lower esophagus.