Background: The clinical significance and manometric profile of patients with high-amplitude peristaltic contractions (“nutcracker esophagus”) is increasingly debated. Some consider it a manometric “curiosity” while others report an association with symptoms including chest pain and dysphagia. Our aim was to assess the symptomatic presentation of patients with distal esophageal amplitudes >180mmHg. Methods: The study population consisted of 39 patients (mean age 55.2 years, M:F 9:30) with distal esophageal body contraction amplitudes >180mmHg (5-10cm above LES). Study patients were taken from a cohort of 549 referred for evaluation of foregut symptoms and undergoing esophageal manometry from 2005 - 2008. The primary symptom was dysphagia in 13 (33%), heartburn in 8 (21%), chest pain in 6 (15%), regurgitation in 5 (13%), bloating in 4 (10%), and vomiting, cough and hiccups in 1 patient (3%) each. Twenty-two had no obvious anatomic abnormality while 17 did (epiphrenic diverticulum in 4, intrathoracic stomach in 4, fundoplication in 5, and peptic stricture in 4). Patients were stratified into 2 groups: A (180-220mmHg; n=23) and B (>220mmHg; n=16.)Results: The proportion of patients presenting with dysphagia increased with increasing contractions amplitudes: 56% (9/16) in those with amplitudes >220mmHg and 17% (4/23) with amplitudes <220mmHg (p<.01). On average, patients presenting with dysphagia had significantly higher amplitudes than patients presenting with other symptoms (253.2mmHg vs. 205.4mmHg, p<.01). Contraction duration (A: 5.4s vs. B: 4.5s, p<.05) and the prevalence of high intrabolus pressure (A: 12/16, 75% vs. B: 8/20, 40%, p<.05) were significantly increased with higher contraction amplitudes, suggesting a relationship to outflow resistance. Interestingly, the resting pressure of the LES (A: 26.6mmHg vs. B: 38.2mmHg, p<.05) increased and the proportion of patients with short abdominal LES length (A: 14/22, 64% vs. B: 4/16, 25%, p<.05) significantly decreased with higher amplitudes. Conclusion: Both symptomatic and physiologic data suggest that “nutcracker” contraction amplitudes in the distal esophagus have clinical significance and are associated with dysphagia, a hypertensive LES, high intrabolus pressures and increased contraction duration.