The Nutcracker Esophagus: A Late Diagnostic Yield Notwithstanding Chest Pain and Dysphagia

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23–78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21–67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 ± 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.     

Case Report: “Deathgrip” Esophagus Segmental Aperistalsis Following Electrical Injury

Esophageal trauma resulting from accidentalinjury has rarely been reported in the literature. Todate, isolated reports of esophageal stricture (1) andoropharyngeal dysphagia (2) have been noted; however, documented focal esophageal dysmotilityresulting from electrical exposure could not be found onliterature review. We therefore present such a uniquecase which interestingly began as a seeminglystraightforward case of food impaction.     

Wide-mouthed Sacculation of the Esophagus: A Cause of Dysphagia after Radiation Therapy

We describe a patient who presented with dysphagia after radiation therapy for Hodgkin’s lymphoma secondary to wide-mouthed sacculation of the upper esophagus on barium esophagography, most likely resulting from localized radiation necrosis of the muscular layer of the esophageal wall. Despite its rarity, radiologists should be aware of this finding as a potential cause of dysphagia after radiation therapy to the neck or chest. Unlike radiation strictures, radiation-induced sacculation of the esophagus probably can be managed conservatively without need for endoscopic dilatation procedures.     

Chest Pain Associated with Nutcracker Esophagus: A Preliminary Study of the Role of Gastroesophageal Reflux

A review of our 402 motility records of patients undergoing evaluation of noncardiac chest pain identified 40 patients with the diagnosis of nutcracker esophagus. Gastroesophageal reflux was found in 13 of 20 patients (65%) who underwent pH studies, and endoscopy detected one patient with erosive esophagitis. Thus, at least 14 (35%) of our nutcracker esophagus patients had evidence of reflux. Twelve of these subjects agreed to enter an open-label therapeutic trial. After 8 wk of intensive antireflux treatment with high doses of ranitidine or omeprazole, repeat 24-h pH studies and endoscopy demonstrated normalization of pH parameters and healing of esophagitis in all patients. Ten (83%) patients obtained significant symptomatic improvement in frequency of pain episodes, number of days with pain, and pain severity. However, repeat manometry showed normalization of motor findings in only two (18%) patients. These observations warrant further placebo-controlled trials. Until more information is available, the results of this study suggest that gastroesophageal reflux should be excluded in patients with noncardiac chest pain and nutcracker esophagus before initiation of smooth muscle relaxant therapy.     

Right Atrial Paraganglioma: A Rare Primary Cardiac Neoplasm as a Cause of Chest Pain

A 37-year-old man presented with chest pain, fever, and tachycardia. Electrocardiography revealed no ST–T wave changes, and cardiac markers were normal. Computed tomography of the chest showed a 7-cm mass in the right atrium. The tumor was successfully resected, and the histopathologic features were consistent with paraganglioma.Key words: Angina pectoris, computed tomography, heart atria/pathology/surgery, heart neoplasms/diagnosis, paraganglioma/diagnosis/surgeryMost primary cardiac tumors are benign; the rarest is paraganglioma, which accounts for less than 1% of all cases.¹ Herein, we report a case of right atrial paraganglioma in which chest pain was the presenting symptom.     

A Remnant Sewing Needle in the Right Ventricle as a Cause of Chest Pain

Sewing needles, albeit a rare case of penetrating cardiac injury, are potentially life‐threatening. We report a case of a self‐inflicted remnant intracardiac sewing needle which is diagnosed with nonspecific chest pain and successfully extracted 23 months after its insertion. Copyright © 2009 Wiley Periodicals, Inc.     

Acid-Provoked Esophageal Spasm as a Cause of Noncardiac Chest Pain

A total of 394 patients with noncardiac chest pain underwent both basal esophageal manometry and combined esophageal motility and acid perfusion studies between 1986 and 1988. On basal esophageal manometry, 275 patients had a normal response, 64 patients had findings of high-amplitude peristalsis or "nut-cracker" esophagus, and 11 patients exhibited changes of diffuse esophageal spasm. Of the 275 patients who had normal findings on basal esophageal manometry, 90 patients (33%) had a positive response on combined esophageal motility and acid perfusion studies, that is, reproduction of chest pain with associated abnormal motility changes. The present study focuses on the 90 patients with acid-provoked esophageal spasm. On acid perfusion study, these 90 patients had a 46.2% rise in deglutition response and a 95% increase in duration compared with a 3.2% and a 4.3% change in values for the control group of healthy volunteers. Of the group with acid-induced spasm, 90.1% had excessive dysmotility changes (repetitive waves, multiple peaks, spontaneous or simultaneous contractions) compared with an incidence of 12.5% in the control group.     

Acute Chest Pain without Obvious Organic Cause before the Age of 40

ABSTRACT Reactivity to mental stress and relaxation was studied in 63 consecutive patients below the age of 40 attending the emergency care unit because of chest pain without obvious organic cause. The results were compared with a control group (n=32). Of the patients, 41% reported chest pain or oppression in the chest during mental stress compared to 10% of the control subjects (p<0.01). During relaxation the subjects in the female patient group reported significantly less ability to relax and had significantly higher respiration rate as compared to the female control group. There were no significant differences between the groups regarding heart rate, blood pressure or end-tidal PCO₂ and there was no evidence of hyperventilation, neither during relaxation nor during mental stress. In combination with our earlier findings of high scores for “type A behaviour”, “neuroticism”, “vital exhaustion” and “stressful life events” these findings indicate that psychosomatic mechanisms may be of great importance for the development of chest pain in this group of patients.