Jackhammer Esophagus

Jackhammer oesophagus (hypercontractile oesophagus) is a motility disorder with excessively forceful oesophageal contractions of normal propagation and normal lower oesophageal sphincter relaxation.

• Chicago classification: at least 20% of swallows with distal contractile integral (DCI) over 8000 mmHg·s·cm, with normal integrated relaxation pressure.
• Prevalence is 0.1 to 2% of patients undergoing manometry; occurs in older adults.
• Mechanism: excessive cholinergic drive and impaired inhibitory input; association with gastro oesophageal reflux disease, opioid use, outflow obstruction, anxiety, and eosinophilic oesophagitis.
• Variants: transient hypercontractility in outflow obstruction; may progress to achalasia type III in some.
• Complications: chronic chest pain, food impaction, weight loss rare.

• Chest pain (non cardiac), severe, squeezing, lasting minutes to hours, often postprandial.
• Dysphagia for solids and liquids, regurgitation, heartburn.
• Pain may mimic angina and respond to nitrates.
• Symptoms can be intermittent and triggered by stress.

• Exclusion of cardiac disease first (ECG, troponin, stress testing).
• Upper endoscopy with oesophageal biopsies (eosinophilic oesophagitis, reflux).
• High resolution manometry: at least 20% of swallows with DCI over 8000 mmHg·s·cm and repetitive high amplitude contractions, normal relaxation of lower oesophageal sphincter. Rule out outflow obstruction and spastic achalasia.
• Barium oesophagram: corkscrew appearance, diverticulum, hiatal hernia.
• pH impedance monitoring for reflux; EndoFLIP for distensibility; CT/ endoscopic ultrasound for suspected obstruction.
• Review medications (opioids, buprenorphine).

• Treat concurrent reflux with PPI (omeprazole 40 mg daily or twice daily).
• Calcium channel blockers: diltiazem 60 to 120 mg three times daily or nifedipine 10 to 20 mg three times daily.
• Nitrates (isosorbide dinitrate 5 to 20 mg before meals), phosphodiesterase 5 inhibitors (sildenafil 50 mg), anticholinergics (hyoscyamine 0.125 to 0.25 mg sublingual) for episodes.
• Neuromodulators: amitriptyline 10 to 50 mg or imipramine 25 mg at night, trazodone, SSRIs; psychological therapies.
• Botulinum toxin A 100 units in four quadrants above the lower oesophageal sphincter or into the body of the oesophagus.
• POEM with an extended myotomy (long myotomy 12 to 16 cm including the hypercontractile segment) for refractory symptoms (success 70 to 90%); pneumatic dilation less effective; surgical myotomy.
• Stop opioids where possible.
• Follow up with symptom scores and repeat manometry if necessary.