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Objective: The objective of this study was to correlate high resolution impedance manometry (HRIM) findings with symptoms in patients diagnosed with nutcracker esophagus based on conventional manometric criteria. Methods: A retrospective review of a prospectively maintained database identified patients with a nutcracker esophagus (distal esophageal amplitude > 180 mmHg). Patients with a history of previous foregut surgery or with type I, II, or III achalasia were excluded. We used two different stratification schemes based on the previously described Chicago classification of normal integrated relaxation pressure (IRP) and distal contractile integral (DCI) values. One stratification scheme was based on IRP: group A (IRP<15 mmHg) and group B (IRP≧15mmHg). The other stratification scheme was based on DCI: group X (DCI≦8000 mmHg/s/cm) and group Y (DCI>8000 mmHg/s/cm). Patients rated their symptoms namely chest pain, heartburn, dysphagia and regurgitation on a scale of 0-3. Chi square test was used to compare categorical variables. Mann-Whitney test was used to compare continuous variables. Results: Thirty patients satisfied the inclusion and exclusion criteria. There were 21 (70%) females. Fifteen patients (50%) presented with dysphagia while 15 patients (50%) presented with chest pain. Twenty-six patients (74%) had spastic waves (DCI>5000 mmHg/s/cm and normal contractile front velocity). Of these 22 (85%) had impaired relaxation i.e. IRP ≧ 15 mmHg. There was no difference in clinical symptoms or manometric variables betwen groups A (7/30) and B (23/30). Group X comprised 7 (24%) patients and Group Y comprised 22 (76%) patients. The number of patients with chest pain was significantly (p=0.023) higher in group Y (14 patients) when compared to group X (1 patient). The mean chest pain score in group Y (mean score=1.5) was significantly (p=0.027) higher than group X (mean score=0.3). There was a positive correlation (R=0.399) between chest pain and DCI which was statistically significant (p=0.032).Conclusion: In nutcracker patients chest pain is associated with increasing DCI.