Hypercontractile Esophagus With Atypical Symptoms

CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Figure. High-resolution impedance manometry of a patient with hypercontractile esophagus. Extremely abnormal contraction (DCI ＞ 8,000 mmHg ‧ sec ‧ cm) is noted. The esophago-gastric junction relaxation is equivocal (integrated relaxation pressure [IRP] = 16 mmHg) but the distal latency (DL ＞ 4.5 seconds) is normal. A 57-year-old man presented with frequent belching for 10 years. Some ambiguous chest discomforts had usually preceded and often disappeared after belching. However, when the discomfort persisted even after belching, he often felt dizziness. Chest pain and gastroesophageal regurgitation were not accompanied. He underwent coronary angiography and tests for ar-rhythmia, but no abnormal findings were found. He had visited many gastroenterologic clinics because of the aggravated symptoms and took several medicines including proton pump in-hibitors for the last 2 years, but the symptoms did not improve. After he was referred to our hospital, he underwent gastro-duodenal endoscopy. Whitish discoloration of gastroesophageal junction was observed, which was minimal changes of reflux esophagitis. Under the suspicion of the combined esophageal dysmotility, high-resolution impedance manometry (HRIM) was recommended with pH monitoring. HRIM in upright position revealed vigorous esophageal contraction which exceeded 8,000 mmHg·sec·cm of distal contractile integral (DCI) in most of the 10 times liquid-swallowing (Figure). Although integrated relaxation pressure was slightly elevated, peristalsis was intact. Also, contractile front velocity and distal latency were within normal range. Collectively, these results were compatible with Jack-hammer esophagus. However, he refused the ambulatory 24-hour esophageal pH monitoring. The patient was prescribed 60 mg of nifedipine daily for 8 weeks and instructed to take 5 mg of flunarizine if he felt dizziness. He eventually reported decreased frequency and se