Volume 128, Issue 5, Pages 1179-1186 (May 2005) Asynchrony Between the Circular and the Longitudinal Muscle Contraction in Patients With Nutcracker Esophagus  Hwoon-Yong Jung, James L. Puckett, Vikas Bhalla, Maria Rojas-Feria, Valmik Bhargava, Jianmin Liu, Ravinder K. Mittal  Gastroenterology  Volume 128, Issue 5, Pages 1179-1186 (May 2005) DOI: 10.1053/j.gastro.2005.02.002 Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 1 Schematics of the catheter system to record pressure and US images. The US transducer is located 2–3 mm distal to the pressure recording site. The catheter/US acquisition system allows one to capture a 360° view of the esophagus. Muscle CSA is obtained by subtracting mucosal CSA (area outlined by the inner line of the muscle layer) from the entire esophageal CSA (area outlined by the outer line of the muscle layer). Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 2 Schematics of the relationship between the onset of lumen collapse, muscle CSA (calculated from the US images), and the manometric contraction. (a) Onset of increased muscle CSA. (b) Onset of contraction pressure. (c) Peak of muscle CSA. (d) Peak of contraction amplitude. The onset of pressure wave is time 0. The onset and end of longitudinal muscle contraction (CSA) are defined as the onset of increase in the CSA and return to baseline, respectively. Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 3 (A) Relationship between M-mode US images, muscle CSA, and the pressure wave in a healthy subject. Note that the onset of lumen collapse occurs at the same time as the onset of muscle CSA. Pressure wave occurs at the same time as the first complete collapse of the lumen on the manometric probe. Peak of manometric contraction and peak CSA occurred with a δ-t ≤0.5 seconds during all 28 swallows at the 2-cm level and all 28 swallows at the 10-cm level. (B) An example of dissociation between circular (cm) and longitudinal (lm) muscle contraction in a patient with nutcracker esophagus. These recordings were obtained 2 cm above the LES. Note the disassociation between the peak pressure and peak muscle CSA. Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 4 Time lag (δ-t) between manometric pressure and muscle CSA. (A) Time lag between the onset of manometric pressure and the onset of muscle CSA is significantly different between healthy subjects and patients with nutcracker esophagus at the 2-cm level. (B) Time lag (δ-t) between the peak of manometric pressure and the peak muscle CSA is significantly longer in patients with nutcracker esophagus at both 2 cm and 10 cm above the LES. Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 5 Factors affecting time lag (δ-t) between peak circular muscle and peak longitudinal muscle contraction. The δ-t correlated with peak pressure, duration of pressure, and peak muscle CSA. Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 6 An example of wide time lag (δ-t) between the peak of muscle CSA and the peak pressure in a patient with nutcracker esophagus with normal amplitude contraction. This swallow sequence showed 1.25-second dissociation and a contraction pressure amplitude of 160 mm Hg. (δt=1.25 sec). Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 7 The duration of pressure wave and muscle CSA in healthy subjects and patients with nutcracker esophagus. Note that the duration of pressure wave in patients is significantly longer than in healthy subjects at the 2-cm level. However, the duration of the increase in muscle CSA is not longer than in healthy subjects at either the 2-cm or 10-cm levels. □, Normal subjects; •, nutcracker esophagus. Gastroenterology 2005 128, 1179-1186DOI: (10.1053/j.gastro.2005.02.002) Copyright © 2005 American Gastroenterological Association Terms and Conditions