 The pathophysiology of nutcracker esophagus may be related to abnormalities in neurotransmitters or other mediators in the distal esophagus.Abnormalities in nitric oxide levels, which have been seen in achalasia, are postulated as the primary abnormality.As GERD is associated with nutcracker esophagus, the alterations in nitric oxide and other released chemicals may be in response to reflux.