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Nutcracker esophagus (now termed Hypercontractile / Jackhammer esophagus in Chicago Classification v3) is an esophageal motility disorder characterized by excessively high-amplitude peristaltic contractions of the esophageal body, with normal peristaltic sequence and normal LES relaxation.

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Named because manometric tracings resemble the crushing force of a nutcracker.
Often considered a cause of non-cardiac chest pain.

Etiopathogenesis

Cause not fully understood.
Thought to be due to excessive excitatory cholinergic innervation → hypercontractile esophageal peristalsis.
Can be primary or associated with GERD, anxiety/stress, opioids, or autonomic dysfunction.
Unlike achalasia or DES, coordination is preserved.

Clinical Features

Chest pain (substernal, angina-like, often severe).
Dysphagia (intermittent, both solids and liquids).
Food impaction sensation.
Rare regurgitation.
Symptoms may be provoked by hot/cold liquids, stress, or exertion.

Radiology

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Diagnosis mainly manometric.

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Modality	Imaging features
Barium Swallow	• Often normal or may show strong tertiary contractions.
• Occasionally “corkscrew-like” appearance (less marked than DES).
XR/CT	Usually unremarkable, may show nonspecific esophageal dilatation if chronic.
Endoscopy	• Typically normal mucosa.
• Useful to exclude reflux esophagitis, stricture, or malignancy.
Manometry	Classic Nutcracker (conventional manometry):
• High peristaltic amplitude (>180–220 mmHg).
• Normal propagation velocity.
• Normal LES relaxation.

Jackhammer esophagus (high-resolution manometry): • Hypercontractile swallows with Distal Contractile Integral (DCI) > 8,000 mmHg·s·cm in ≥20% of swallows. • Normal LES relaxation (integrated relaxation pressure, IRP). |