A Case of Nutcracker Esophagus Associated with Chest Pain and Antidepressant Treatment

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1 2001 ; 7 : *, * * * * * * * = Abstract = A Case of Nutcracker Esophagus Associated with Chest Pain and Antidepressant Treatment Suck Chei Choi, M.D.*, Sang Yeol Lee, M.D., Ji Hun Choi, M.D.*, Mi Ryeong Sim, M.D.*, Joo Jin Yeom, M.D.*, Jung Hyeon Park, M.D.*, Tae Hyeon Kim, M.D.*, and Yong Ho Nah, M.D.* Departments of Internal Medicine* and Psychiatry Wonkwang University College of Medicine, Iksan, Korea Nutcracker esophagus is thought to be a common cause of noncardiac chest pain although has not been clearly established, and the effective treatment is lacking. The usual forms of therapy for noncardiac chest pain by nutcracker esophagus have been directed traditionally toward reducing esophageal hypermotility and muscle tone such as nitrate and calcium channel blocker. However, the results of this treatment in the long term care of patient with esophageal symptoms have been generally disappointing and often unsatisfactory. Recently, psychosomatic aspect of esophageal motility disorder including antidepressant treatment has been accepted in the treatment of noncardiac chest pain. We report a 48 year old female with nutcracker esophagus associated chest pain by ambulatory 24 hour esophageal manometry who failed diagnosis by conventional manometry. The symptoms of chest pain, quality of life, and depression of the patient were improved after antidepressant medication. (Korean Journal of Gastrointestinal Motility 2001;7: ) Key Words: Chest pain, Nutcracker esophagus, Antidepressant :, ( ) Tel : (063) , Fax : (063) , medcsc@wmc.wonkwang.ac.kr, 50%. 1,. 2 30%,,

228 Korean Journal of Gastrointestinal : Vol. 7, No. 2, 2001,. 3,, 4. 5-6 nifedipine diltiazem, 7-8 9.,, 1.,,.,. ergonovine 104 mmhg, 3, 3.3cm/ Bernstein. 4 cm, 22 mmhg, 7. 24 2,, (Fig. 1). 48. 1.,. 5,,, M-SPECT, ergonovine, 125 mmhg, 3 Bernstein.

2 228 Korean Journal of Gastrointestinal : Vol. 7, No. 2, 2001,. 3,, nifedipine diltiazem, ,, 1.,,.,. ergonovine 104 mmhg, 3, 3.3cm/ Bernstein. 4 cm, 22 mmhg, ,, (Fig. 1) ,. 5,,, M-SPECT, ergonovine, 125 mmhg, 3 Bernstein., (32-55 mmhg) 10 diltiazem 30 mg 3, 7., 120/80 mmhg, 70 /, 20 /. Fig. 1. Ambulatory esophageal pressure monitoring, recorded from one of Nutcracker esophagus during chest pain. The longitudinal line marks esophageal contraction 95,,,,,,

3 Suck Chei Choi, et al : A Case of Nutcracker Esophagus Associated with Chest Pain and Antidepressant Treatment 229 Table 1. Self-reported Quality of Life using Shor-Form 36 Health Survey-Korean Version in Pre-treatment and Post-treatment with Mirtazapine SF-36-K Pre-treatment Post-treatment Physical functioning Role-physical Bodily pain General health Vitality Social functioning Role-emotional Mental health , , Beck (Beck Depression Inventory: BDI) BDI Beck BDI 37. (Diagnostic and Statistical Manual for Mental Disorder- : DSM-IV) 15. (norepinephrine) (serotonin) mirtazapine mg mg 4.. mirtazapine 4. 4 BDI 15 BDI (Short-Form 36 Health Survey-Korean Version : SF-36-K) (Table 1). SF-36 Ware Sherbourne ,,,

4 230 : 7 2, 2001, %. 4,19,, ,,,. Barham Stein , nitrate,,.,, , Richter 27, Smout 28., Ringel Drossman 29,.,,, 30, 31 84%, 3 70% 23,,.., trazodone, imipramine BDI, 5-HT3 mirtazapine. mirtazapine

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6 232 Korean Journal of Gastrointestinal : Vol. 7, No. 2, 2001 chest pain: current controversies in pathogenesis, diagnosis, and therapy. Ann Intern Med 1989; 110: Barham CP, Gotley DC, Fowler A, Mills A, Alderson D. Diffuse oesophageal spasm: diagnosis by ambulatory 24 hour manometry. Gut 1997;41: Stein HJ, DeMeester TR, Eypasch EP, Klingman RR. Ambulatory 24-hour esophageal manometry in the evaluation of esophageal motor disorder and noncardiac chest pain. Surgery 1991;110: Clouse RE. Spastic disorders of the esophagus. Gastrotenterologist 1997;5: Reidel WL, Clouse RE. Variations in clinical presentation of patients with esophageal contraction abnormalities. Dig Dis Sci 1985;30: Clouse RE, Staiano A. Manometric patterns using esophageal body and lower sphincter characteristics. Finding in 1013 patients. Dig Dis Sci 1992;37: McCord GS, Staiano A, Clouse RE. Achalasia, diffuse spasm and non-specific motor disorders. Baillieres Clin Gastroenterol 1991;5: Richter JE, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology 1986;91: Smout AJ, DeVore MS, Dalton CB, Castell DO. Cerebral potentials evoked by oesophageal distension in patients with non-cardiac chest pain. Gut 1992;33: Ringel Y, Drossman DA. Treatment of patients with functional esophageal symptoms: is there a role for a psychotherapeutic approach? J Clin Gastroenterol 1999;28: Drossman DA. Importance of psyche in heartburn and dyspepsia. Aliment Pharmacol Ther 1997;11: Whitehead WE, Palsson OS. Is rectal pain sensitivity a biological marker for irritable bowel syndrome: psychological influences on pain perception. Gastroenterology 1998;115: Clouse RE, Lustman PJ, Eckert TC, Ferney DM, Griffith LS. Low-dose trazodone for symptomatic patients with esophageal contraction abnormalities: a double-blind, placebo-controlled trial. Gastroenterology 1987;92: Peghini P, Katz P, Castell D. Imipramine increase pain and sensation thresholds on esophageal balloon distension in humans. Gastroenterology 1997;112:A Montgomery SA. Safety of mirtzapine: a review. Int Clin Psychopharmacol 1995;10(suppl 4): Thomas SG. Irritable bowel syndrome and mirtazapine. Am J Psychiatry 2000;157: Mega M, Cummings JL, Salloway S. The limbic system: an anatomic, phylogenetic, and clinical perspective. J Neuropsychiatry Clin Neurosci 1997;9:

The Frequency of Gastroesophageal Reflux Disease in Nutcracker Esophagus and the Effect of Acid-Reduction Therapy on the Motor Abnormality

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