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the First Reported High-Resolution Manometry Changes of Sublingual Hyoscyamine in a Patient With Hypercontractile Esophagus (Jackhammer Esophagus).
Joshua a. Boys*, Jeffrey a. Hagen
Thoracic Surgery, Keck Hospital of USC, Los Angeles, CA
Introduction: The antimuscarinic drug hyoscyamine is used as an adjunct to the treatment of gastrointestinal disorders such as irritable bowel syndrome. The effects of hyoscyamine on esophageal motility by high-resolution manometry (HRM) have never been reported. Here we present HRM findings in a patient with esophagogastric junction (EGJ) outflow obstruction and hypercontractile esophagus (jackhammer esophagus) before and after taking sublingual hyoscyamine.
Case Description: A 71 year-old male with a 4 year history of heartburn and regurgitation presented with 2-3 years of progressive dysphagia described as a globus sensation in his low chest. He also complained of dysphagia in the cervical esophagus to both liquids and solids which caused painful throat spasms approximately once a week and causing him not be able to eat or drink for days at a time. Five months prior he underwent upper esophageal dilation with an 18mm balloon without much improvement in symptoms. His remaining past medical and surgical history is non-contributory. His medications at the time of presentation were a pantoprazole twice daily, terazosin, simvastatin and aspirin. On EGD there were no visible esophageal abnormalities and a 1 cm hiatal hernia. On video esophagram there was evidence of esophageal dysmotility especially noted at the upper esophagus with cephalic escape and occasional tertiary contractions. The initial HRM showed 9 of 10 swallows peristaltic with an average distal contractile integral (DCI) of 44,000 mmHg-cm-s and a maximum DCI of 70,317 mmHg-cm-s (figure). At this time the patient was diagnosed with jackhammer esophagus. Between visits, the patient was prescribed 0.125mg sublingual (SL) hyoscyamine by an outside clinic. On his return visit the patient stated that the SL hyoscyamine helped relieve the painful throat spasms. Initial and repeated HRM studies before and 20 minutes after SL hyoscyamine are shown (table). On Post-hyoscyamine HRM there were 5 peristaltic and 5 simultaneous swallows with an average DCI of 2500 mmHg-cm-s and maximum DCI of 6000 mmHg-cm-s (figure).
Discussion: Hypercontractile esophagus (jackhammer esophagus) is defined by the Chicago criteria as a maximum DCI > 8000 mmHg-cm-s, which this patient met on his initial and pre-hyoscyamine studies. After taking SL hyoscyamine, the HRM showed a decrease in average and maximum DCI with more simultaneous swallows. The efficacy of SL hyoscyamine for the treatment of a hypercontractile esophagus is anecdotal; however this case shows manometric evidence of decreased esophageal contractile pressures after taking SL hyoscyamine and may be useful in select cases as a potential treatment adjunct.
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