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Jackhammer Esophagus Very Common After Lung Transplantation

Key findings

  • Jackhammer esophagus (JE) is a rare hypercontractile disorder, currently defined as ≥20% of swallows having a distal contractile integral >8,000 mmHg × s × cm and normal latency on manometry
  • One case report has linked JE to lung transplantation, and this retrospective study investigated the incidence of JE in 59 patients who underwent esophageal manometry before and after lung transplantation
  • 25% of patients had a new diagnosis of JE after transplantation
  • Patients with newly diagnosed JE were significantly older and more often had chronic obstructive pulmonary disease as the indication for transplantation, compared with those who did not develop JE
  • There was no difference between the two groups in post-transplantation outcomes

Jackhammer esophagus (JE) is a rare hypercontractile esophageal disorder, detected in about 4% of patients who undergo esophageal manometry. Its cause is unknown, but it's been associated with another rare condition, esophagogastric junction outflow obstruction, as well as with gastroesophageal reflux disease (GERD).

A 2013 case report (published in the Journal of Neurogastroenterology and Motility) described JE following lung transplantation (LT), and its authors speculated that JE may have occurred because of vagal nerve injury as a result of the surgery. GERD has also been reported after LT, and gastroparesis occurs in 23% to 91% of cases after LT, presumably because of vagal nerve injury.

Intrigued by these connections, Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory in the Division of Gastroenterology at Massachusetts General Hospital, Gastroenterologist Braden Kuo, MD, MSc, director of the Center for Neurointestinal Health, and colleagues conducted the first study of the incidence of JE after LT. In the Journal of Clinical Gastroenterology, they report that JE is very common in that setting, with clearly identifiable risk factors.

Study Details

In a multicenter study, the researchers reviewed records on 244 adults who underwent LT at either Mass General or Brigham and Women's Hospital between July 2010 and November 2017. They defined JE according to version 3.0 of the Chicago classification of esophageal motility disorders (published in Neurogastroenterology and Motility): ≥20% of swallows having a distal contractile integral >8000 mmHg × s × cm and normal latency on manometry.

Incidence and Risk Factors of JE

A total of 59 patients underwent esophageal manometry both before and after LT, and JE was a new diagnosis in 15 of them (25%).

Compared with patients who did not have JE after LT, those newly diagnosed with JE after LT were:

  • Older (52 vs. 61; P = .02)
  • More likely to undergo LT because of chronic obstructive pulmonary disease (17% vs. 48%; P = .03)
  • Less likely to undergo transplantation because of cystic fibrosis (36% vs. 7%; P = .04).
  • More likely to be female (33% vs. 60%; P = NS)

Other Comparisons

There were no significant differences between the two groups in pretransplant manometry findings or post-transplant outcomes. In particular, there was no difference in the occurrence of post-transplant gastroparesis, which may be a surrogate marker of vagal nerve injury.

Only eight patients underwent pH testing after LT, so it wasn't possible to assess whether GERD contributed to the development of JE after LT.

Implications for Practice

JE should be added to the list of gastrointestinal disorders that frequently occur after lung transplantation. Whether JE affects transplant outcomes, such as allograft rejection, remains undetermined, and gastroenterologists should remain alert to that possibility.

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