Do the clinic aspects of nutcracker esophagus parallel the features of the irritable bowel syndrome ?
J-E. Richter (Birmingham)
Many characteristics of painful esophageal motility disorders, particularly the nutcracker esophagus, are similar to those of the irritable bowel syndrome.
These syndromes occur predominantly in women and symptoms frequently overlap. In my laboratory, we found that over half the patients with painful esophageal motility disorders had symptoms compatible with the irritable bowel syndrome, compared with only 28 p. cent of age-match patients in a medical clinic population (p < 0.01). Other researchers [1] found a similar high frequency of lower gastrointestinal symptoms in patients with esophageal motility disorders other than achalasia.
Similar to patients with irritable bowel syndrome, nutcracker patients frequently have psychological abnormalities when assessed by psychological inventories or a structured psychiatric interview. We gave the Millon Behavioral Health Inventory to groups of patients with chest pain and the nutcracker esophagus, patients with irritable bowel syndrome, patients with benign structural abnormalities of the esophagus and healthy controls [2]: patients with the nutcracker esophagus and patients with irritable bowel syndrome had significantly higher scores than all other groups of patients on the Somatic Anxiety and Gastrointestinal Susceptibility scales. This pattern suggested that these patients tended to have excessive concerns about somatic functions, and to have more frequent and severe gastrointestinal symptoms under stress.
Our results are complemented by those of Clouse and Lustman [3], who gave the Diagnostic Interview Schedule, a structured psychiatric interview, to 50 consecutive patients referred for esophageal manometry: psychiatric diagnoses were made in 21 of 25 patients with motility abnormalities in the distal esophagus (18 of these patients had nutcracker esophagus or its variants). In contrast, psychiatric diagnoses were given to only four of thirteen patients with normal manometric findings. The most common psychiatric diagnoses were depression, anxiety, and somatization disorders which are similar to the psychiatric diagnoses most frequently found in patients with the irritable bowel syndrome [4].
Nutcracker patients with chest pain have been found to have lower pain thresholds for esophageal balloon distention [5], an effect similar to rectal balloon studies in irritable bowel patients [6]. In both groups, this abnormal sensory perception appears to be independent of gut contractile activity or increased wall tension. These patients seem to be generally sensitive to a variety of esophageal stimuli, some of which normally do not cause chest pain in healthy subjects.
This probably explains the high frequency of chest pain episodes not associated
with definable esophageal abnormalities when the nutcracker patients are studied with 24-hour pH and pressure monitoring [7].
Finally, both the esophageal and colonic disorders are manifested by abnormal contractions which may be induced in response to physical or psychological stressors. We have recently observed that the cold pressor test, unpredictable loud noises, and difficult intellectual tasks can produce significant increases in distal esophageal contraction amplitudes among esophageal chest pain patients, particularly those with nutcracker esophagus [8].
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