Diagnosis Oesophageal manometry; the diagnosis is made at intraoesophageal pressure above 180 mm Hg, a pressure fancifully likened to that of a nutcracker, hence the name
• Reduce risk factors Weight loss; it is unclear if acid suppression, to reduce oesophageal reflux, is effective
• Medical therapy Calcium-channel blockers to relax the lower oesophageal sphincter (LOS) and reduce dysphagia; diltiazem; nitrates—e.g., pre-prandial isosorbide dinitrate—may also relax the LOS; phosphodiesterase inhibitors—e.g., sildenafil—may be of use; trazodone, an anti-depressant, may reduce visceral sensitivity and chest pain
• Endoscopic therapy Botulinum toxin (Botox) temporarily improves symptoms; balloon dilation to stretch LOS muscles may improve work
• Surgery As a last resort, a Heller myotomy can disrupt the LOS and the myenteric plexus that innervates it.