Phenotypes and Clinical Context of Hypercontractility in High-Resolution Esophageal Pressure Topography (EPT)

Abstract

Backgrounds & Aims This study aimed to refine the criteria for esophageal hypercontractility in high resolution esophageal pressure topography (EPT) and examine the clinical context in which it occurs. Subjects & Methods 72 control subjects were used to define the threshold for hypercontractility as a distal contractile integral (DCI) greater than observed in normals. 2,000 consecutive EPT studies were reviewed to find patients exceeding this threshold. Concomitant EPT and clinical variables were explored. Results The greatest DCI value observed in any swallow among the control subjects was 7,732 mmHg-s-cm; the threshold for hypercontractility was established as a swallow with DCI >8,000 mmHg-s-cm. 44 patients were identified with a median maximal DCI of 11,077 mmHg-s-cm, all with normal contractile propagation and normal distal contractile latency, thereby excluding achalasia and distal esophageal spasm. Hypercontractility was associated with multipeaked contractions in 82% of instances leading to the name Jackhammer Esophagus . Dysphagia was the dominant symptom although subsets of patients had hypercontractility in the context of EGJ outflow obstruction, reflux disease, or as an apparent primary motility disorder. Conclusion We describe an extreme phenotype of hypercontractility characterized in EPT by the occurrence of at least a single contraction with DCI > 8,000 mmHg-s-cm, a value not encountered in control subjects. This phenomenon, branded Jackhammer Esophagus was usually accompanied by dysphagia and occurred both in association with other esophageal pathology (EGJ outflow obstruction, reflux disease) or as an isolated motility disturbance. Further studies are required to define the pathophysiology and treatment of this disorder.

Radiofrequency Catheter Ablation for Atrial Fibrillation Elicited “Jackhammer Esophagus”: A New Complication Due to Vagal Nerve Stimulation?

“…In particular, Jackhammer esophagus (JE) is a newly described entity identified and defined as a distal contractile integral (DCI) of greater than 8000 mmHg · cm · sec on single or multiple swallows in the presence of normal lower esophageal sphincter (LES) relaxation; this DCI value was not encountered in control subjects. 3 Also, JE is characterized by repetitive and high-amplitude contractions and it is usually accompanied by dysphagia or chest pain, occurring either in association with esophageal pathology or as an isolated motility disturbance. 4 Its physiopathology remains unclear; in fact some JE patients showed an associated mechanical outflow obstruction of the esophagogastric junction, others an underlying reflux disease, and finally some are thought to be caused by a primary esophageal muscle hypercontractility.…”

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders

“…10,11,31 The term Jackhammer esophagus was chosen because these patients more often had strong multipeaked contractions. 40 Multipeaked contractions however, were not associated with more symptoms or a better treatment response. For this reason, Jackhammer esophagus was defined as at least two swallows with a DCI ≥ 8000 mmHg·cm·sec, irrespective of the presence of multipeaked contractions.…”

“…However, asymptomatic controls sometimes have individual swallows with a DCI ≥ 5000 mmHg·cm·sec, but almost never with a DCI ≥ 8000 mmHg·cm·sec, while symptomatic patients sometimes do have swallows with a DCI ≥ 8000 mmHg·cm·sec and in order to reach this DCI level these contractions usually also have spastic characteristics such as multipeaks, repetitive patterns and short distal latency. 40 A DCI ≥ 8000 mmHg·cm·sec was found to be associated with chest pain and dysphagia and with positive response to achalasia treatment, thus clinically relevant. 10,11,31 The term Jackhammer esophagus was chosen because these patients more often had strong multipeaked contractions.…”

“…However, isolated elevated peristaltic wave amplitude is usually not associated with symptoms and can be found in healthy subjects as well. 40 For this reason, a new parameter was introduced to measure the vigor of peristalsis: the DCI. This is a multiplication of length, duration, and amplitude of contractions.…”

Esófago en martillo neumático (Jackhammer), serie de casos y revisión del tema

“…Richter y Castell (11), realizaron un estudio en el que encontraron que menos del 5% de los pacientes con esta sintomatología presentaban trastornos de la peristalsis demostrables por manometría esofágica. La prevalencia combinada de espasmo esofágico distal, acalasia espástica y esófago en martillo neumático, es tan solo de aproximadamente el 2% (12,13). El deterioro del tránsito del bolo esofágico, puede ser la causa de las contracciones espásticas, lo cual puede explicar la disfagia.…”