The primary symptom of jackhammer esophagus? It’s not chest pain, study finds

The most common symptom of jackhammer esophagus may be dysphagia, not chest pain, according to a small study published recently in the Journal of Clinical Gastroenterology.

Previously known as nutcracker (or hypercontractile) esophagus, this motility abnormality has been historically associated with noncardiac chest pain.

“Although jackhammer reflects hypercontractility akin to its predecessor, nutcracker esophagus, it does not appear that noncardiac chest pain is the predominant symptom in our study population,” wrote Joshua Sloan, DO, a third-year gastroenterology fellow at Einstein Medical Center, Philadelphia, PA, and colleagues. “Our finding that dysphagia is the predominant symptom over noncardiac chest pain is consistent with other small studies that have been performed.”

In 2014, the Chicago Classification of esophageal motility disorders (version 3.0) eliminated the definition of nutcracker esophagus, but included jackhammer esophagus for the first time. The classification defined jackhammer esophagus as the occurrence of ≥ 20% of swallows with a distal contractile integral (DCI) > 8,000 mm Hg per second per centimeter, and normal latency.

“As the definition of hypercontractile esophagus has evolved to jackhammer esophagus, the question remains if noncardiac chest pain is the most predominant symptom associated with this diagnosis,” the authors wrote. “Furthermore, it remains to be determined if the DCI correlates with symptoms.”

To find out, the researchers performed a retrospective chart review of motility studies between 2011 and 2016. They found 17 confirmed cases of jackhammer esophagus measured by high-resolution manometry.

A surprising finding

Of these cases, more presented with dysphagia (8 patients, 47%) than with noncardiac chest pain (5 patients, 29%). Another 4 patients (24%) presented with other symptoms, such as cough, heartburn, or regurgitation. The results also showed that 15 of the 17 patients (88%) had normal bolus transit for both liquid and viscous swallows.

“This finding is surprising given that nutcracker esophagus was historically associated with noncardiac chest pain, and jackhammer esophagus is an evolution of that former diagnosis,” Dr. Sloan and coauthors noted. “It is unclear why dysphagia would be the predominant symptom in light of finding normal bolus transit in almost all of our subjects. A larger sample size is needed to clarify this finding.”

Results also showed that the average DCI wasn’t significantly different between patients with noncardiac chest pain and those with dysphagia (P=0.41). Also, the average DCI of dysphagia patients wasn’t significantly greater than those with other symptoms (P=0.26). However, patients with noncardiac chest pain did have a significantly higher DCI when compared with patients with other symptoms (P=0.05).

“We believe there is a relationship of the DCI with symptom presentation, though the sample size is too small to fully support this at present,” wrote Dr. Sloan and coauthors.

The sample size was also too small to indicate the best treatment for these patients. “Future studies should be performed to identify the most effective target for therapy, whether it is treating the DCI or if treating esophageal sensation with tricyclic antidepressants or other drugs is more efficacious,” the authors concluded.