New diagnostic criteria for nutcracker esophagus using conventional water-perfused manometry: a comparison between nutcracker esophagus with and without gastroesophageal reflux disease.

BACKGROUND AND AIM: Controversy continues as to whether nutcracker esophagus (NE) is a 'real' manometric disease due to its poor correlation with clinical symptoms such as chest pain or dysphagia. While new NE criteria were proposed in a recent study, that study included NE patients both with and without gastroesophageal reflux disease (GERD). We aimed to analyze both general NE (with or without GERD) and pure NE (without GERD) patients in terms of distal esophageal amplitude (DEA) and its correlation with symptoms.

METHODS: Using previously known normal DEA values (mean and SD), patients were stratified into three different groups: group A (DEA 180 to 220 mmHg, 2 to 3 SD), B (DEA 220 to 260 mmHg, 3 to 4 SD), and C (DEA > 260 mmHg, > 4 SD).

RESULTS: A total of 72 patients who simultaneously underwent esophageal manometry and 24-h pH monitoring were diagnosed with NE. They were separated into groups A (n = 43), B (n = 18), and C (n = 11). Although the proportion of general NE patients with symptoms appeared to be greater in group A (65.6%) than in group C (90.9%), statistical analysis showed that this was not a significant correlation (P = 0.07). Pure NE patients were defined as those returning negative findings after 24-h pH monitoring. These patients were separated into three groups based on the same DEA criteria as above: group A-1 (n = 33), B-1 (n = 11), C-1 (n = 8). The proportion of patients with symptoms increased from 54.5% in group A-1 to 87.5% in group C-1, and this correlation was found to be significant (P < 0.05).

CONCLUSIONS: There exists in the general NE population a subset with pure NE. DEA values correlated with symptoms in this subset.