Prospective cohort study of mother-to-infant infection and clearance of hepatitis C in rural Egyptian villages

Although persistent transmission of hepatitis C virus (HCV) from infected mothers to their infants is reported in 4-8%, transient HCV perinatal infection also occurs. This prospective cohort study determined perinatal HCV infection- and early and late clearance-rates in 1,863 mother-infant pairs in rural Egyptian villages. This study found 15.7% and 10.9% of pregnant women had HCV antibodies (anti-HCV) and HCV-RNA, respectively. Among 329 infants born of these mothers, 33 (10.0%) tested positive for both anti-HCV and HCV-RNA 2 months following birth-29 (12.5%) having HCV-RNA positive mothers and 4 (with transient infections) having mothers with only anti-HCV. Fifteen remained HCV-RNA positive at one and/or 2 years (persistent infections), while 18 cleared both virus and antibody by 1 year (transient infections). Among the 15 persistent cases, 7 cleared their infections by 2 or 3 years. At 2- to 6- and at 10- to 12-month maternally acquired anti-HCV was observed in 80% and 5% of infants, respectively. Four perinatally infected and one transiently infected infant were confirmed to be infected by their mothers by the sequence similarity of their viruses. Viremia was 155-fold greater in mothers of infants with persistent than mothers of infants with transient infections. Maternal-infant transmission of HCV is more frequent than generally reported. However, both early and late clearance of infection frequently occurs and only 15 (4.6%) and 8 (2.4%) infants born of HCV-RNA positive mothers had detectable HCV-RNA at one and 2-3 years of age. Investigating how infants clear infection may provide important information about protective immunity to HCV.

A new phenylpropanoid glycoside from Leucas indica Linn

A new phenylpropanoid glycoside, alpha-L-rhamnopyranosyl-(1 --> 3)-O-alpha-L-rhamnopyranosyl-(1 --> 6)-1-O-caffeoyl-beta-D-glucopyranoside (1) along with two known phenylethanoid glycosides (2-3) has been isolated from the aerial parts of Leucas indica Linn. Their structures were deduced from the spectroscopic studies and compared with the literature values.

Aflatoxins as a risk factor for hepatocellular carcinoma in Egypt, Mansoura Gastroenterology Center study

BACKGROUND/AIMS

Aflatoxin B1 (AFB1) is an important food-borne mycotoxin. The co-contamination of foodstuffs with this mycotoxin is well known and has been possibly implicated in the development of hepatocellular carcinoma in high risk regions around the world. This study investigates the serum aflatoxin B1 in patients with hepatocellular carcinoma and compares it to a control group.

METHODOLOGY

From January 2005 to January 2006, 80 cases with hepatocellular carcinoma diagnosed in the Gastroenterology center, Mansoura University, Egypt and 20 healthy subjects used as a control group were enrolled in the study. All patients were evaluated for age, sex, residence, occupation, history of other medical diseases, anti-bilharzial treatment, blood transfusion, viral markers, liver functions and serum level of aflatoxin B1.

RESULTS

The mean age of our patients was 52.88 +/- 7.27 years versus 53.17 +/- 6.78 years for the controls, p>0.05. The serum level of AFP1 was highly significant in HCC patients compared with control (32.47 +/- 92.46 versus 7.33 +/- 5.5 P<0.0001) and it was statistically high between 51:60-years-old (P<0.05). Males represented 82.5% of the patients versus 17.5% for females. AFB1 was higher in males compared with females (P<0.05), higher in rural residents compared with urban residents (P<0.05), higher in Kafer Elchek government are versus others (P<0.01) and higher in farmers compared with those with other occupations (P<0.05). The serum level of AFB1 was high among patients with a history of anti-bilharzial treatment with tarar emetic versus oral treatment by Brazequantil (P<0.05). Hepatitis C antibody was positive in 70% of the patients. The serum level of AFB1 was statistically high in HCV-positive patients compared with HCV-negative ones (P<0.05) but showed no statistical significance in HBs-positive patients compared with HBs-negative ones (P>0.05). The serum level of AFB1 was statistically high in Child class B patients compared with class A (P<0.05), high in patients with tumor size > 5 cm compared with tumor size < 5 cm (P<0.05), high in right lobe tumor patients compared with left lobe tumor (P>0.05), high in multifocal hepatoma patients compared with single lesion patients (P<0.05). The serum level of AFB1 showed a statistically significant positive correlation with serum SGPT and alpha-fetoprotein.

CONCLUSIONS

Aflatoxin B1 may play an important role in the occurrence of HCC in the north Nile delta area and especially in males, farmers, and rural residents, HCV infection, cirrhotic liver and multifocal hepatoma patients. Aflatoxin B1 in high concentration is associated with high incidence of chronic HCV, and affects hepatic parenchyma and multifocal lesions.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux (DGER) to endoscopic severity in patients with GERD and Barrett's esophagus.

METHODS

Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to non-erosive reflux disease (NERD), erosive reflux disease (ERD) and Barrett's esophagus (BE). Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were done to all patients.

RESULTS

Seventy one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed that 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux only, 18 (19.8%) had bile reflux only and 18 patients (19.8%) had no evidence of abnormal reflux. The percentage of the total time of bilirubin absorbance above 0.14, in 71 patients with ERD was (8.18 +/- 11.28%), and in 9 patients with BE was (15.48 +/- 30.48%) which was significantly greater than that in 11 patients with NERD (4.48 +/- 8.99%), p < 0.05 and p = 0.01 respectively. All BE patients had abnormal esophageal bile reflux (3 bile alone and 6 mixed bile and acid); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (13 bile alone and 31 mixed bile and acid); meanwhile 15 of them (21.2%) had abnormal acid exposure alone. Of the 11 patients with NERD, 4 patients (36.4%) had abnormal esophageal bile reflux, 2 of them mixed with acid.

CONCLUSIONS

The Bilitec method reliably identifies the presence of bilirubin and quantitatively detects duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in GERD patients in this study. Bile reflux either alone or mixed with acid reflux contributes to the severity of erosive and non-erosive reflux disease as well as to Barrett's esophagus.

Quality of life and patient satisfaction 3 months and 3 years after laparoscopic Nissen's fundoplication

BACKGROUND/AIM

This study is based on studying the quality of life and degree of satisfaction among gastroesophageal reflux disease (GERD) patients after Laparoscopic Nissen's fundoplication (LNF) operations.

SUMMARY BACKGROUND DATA

A GERD patient is most interested in symptom relief, whereas his surgeon will also be interested in the improvement of anatomical and functional investigations.

MATERIALS AND METHODS

One hundred patients with symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LNF in El-Mansoura Gastroenterology Center between 2002 and 2004. All patients completed the Gastroesophageal Reflux Disease-Health Related Quality Of Life (GERD-HRQL) questionnaire both pre- and postoperatively (early within 3 months after operation and late after 3 years). Furthermore, all patients were given a form with 4 grades (excellent, good, fair and poor) and they were requested to freely assess both the early and late clinical outcomes.

RESULTS

There was statistically significant improvement in all the items of the GERD-HRQL questionnaire, both early and late (P < 0.001). With regard to patient satisfaction; only 58 cases showed excellent clinical satisfaction early postoperatively, while 29, 8 and 5 patients showed good, fair and poor responses, respectively. These figures improved on late followup (P < 0.05), i.e., 76 excellent, 16 good and 8 fair results.

CONCLUSIONS

LNF improves all the items of quality of life among GERD patients significantly (P < 0.001). Patient satisfaction after LNF improves with time; 58 cases showed early postoperative excellent clinical satisfaction as compared to 76 late cases (P < 0.05). However, LNF may not be the standard management of reflux symptoms, particularly from some patients' perspective.

Duodenogastroesophageal reflux: results of medical treatment and antireflux surgery

BACKGROUND/AIMS

Recent studies have shown that reflux of the duodenal content to the esophagus plays an important role in esophageal mucosal damage. The aim of the study is to compare the duodenogastroesophageal (DGER) reflux with the severity of reflux esophagitis and evaluate its response to either medical and/or antireflux surgery.

METHODOLOGY

Ninety-six patients with DGER were subjected to thorough history, upper GI endoscopy, barium study, esophageal manometry and 24-hr esophageal pH metry combined with Bilitec 2000. Medical treatment was given for all, while Nissen fundoplication was done for 28 patients. All patients were evaluated after Nissen fundoplication and treatment.

RESULTS

The age of studied patients was 36.26+/-12.7 years with male to female ratio 2:1. The chief symptom was heartburn in 73 (76%) patients. Upper GI endoscopy revealed, 30 (31.2%) patients had grade I reflux, 30 (31.2%) patients had grade II reflux, 7 patients had grade III reflux, 5 patients had grade VI reflux, Barrett's esophagus in 14 patients (14.5%), hiatus hernia (HH) in 26 (27%) patients. Barium study revealed that, 40 (41.6%) patients had evidence of reflux, while 34 (35.4%) patients had reflux with HH. Esophageal motility revealed the mean LESP (12.7+/-7.6), 68 patients (70.8%) had normotensive body while ineffective esophageal body motility was encountered in 28 (29.1%) patients. Esophageal 24-hr pH study and Bilitec 2000 revealed that 54 (56.2%) patients had bile reflux with pathological acid reflux, while 42 (43.7%) patients had bile reflux in alkaline pH. Medical treatment gave excellent to good response in 68 (70.8%) patients, while Nissen fundoplication was done for 28 (29.2%) patients. Endoscopic examination 6 months after Nissen fundoplication showed marked improvement in endoscopic injury. Barium study after Nissen fundoplication revealed repair of HH and control of GERD in all patients except one. Esophageal motility, 24 hr pH study and Bilitec 2000, after 6 months of Nissen shows high significant increase in LESP, decrease in acid and bile reflux. No significant difference between open or laparoscopic fundoplication in LESP, acid and bile reflux.

CONCLUSIONS

DGER in acid medium is more injurious to the esophagus than DGER in alkaline pH. The severity of esophageal injury does not correlate with the severity of acid or bile reflux but has a direct correlation with impaired distal esophageal motility. Medical treatment gives satisfactory control of symptoms and healing of esophageal lesion in 70% of DGER. The response to medical treatment does not depend on the severity of esophageal injury but depends on the severity of bile and acid reflux. Nissen fundoplication in refractory patients, either open or laparoscopic, was effective in control of heartburn in 95% of patients contrary to 50% in mixed symptoms.

Portal hypertensive duodenopathy: clinical, endoscopic, and histopathologic profiles

OBJECTIVE

Description of the clinical, endoscopic, and histopathologic detailed profiles of duodenal affection in portal hypertensive patients.

METHODS

A total of 105 patients with chronic liver disease and portal hypertension (PH) were included, upper endoscopy was performed, and two duodenal biopsies were obtained from the bulb and distal to the ampulla, for histopathologic examination. Twenty dyspeptic patients with normal upper endoscopy were included as controls.

RESULTS

Of the portal hypertensive patients, 54 (51.4%) had endoscopic duodenopathy (ED) lesions including erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern, duodenal varices, and mixed lesions. ED was significantly higher in patients having severe than mild gastropathy (56.8% vs 23.5%, P<0.05) with no relation to size of esophageal varices or variceal bleeding. ED was a source of overt bleeding in 6.7% and occult bleeding in 2.9% of patients. Histopathologically, vascular changes included either capillary congestion (in more than half of biopsies) or capillary angiogenesis (in more than one-quarter of biopsies). Nonvascular changes included increased apoptosis (in about 16% of biopsies), fibrous proliferation (in about 4% of biopsies), and villous changes (in 11.4% of distal biopsies). All changes were not statistically different between patients with and without ED. In dyspeptic patients, only minimal histopathologic changes were noted.

CONCLUSIONS

ED is significantly higher in patients with severe gastropathy and causes gastrointestinal bleeding in 9.5% of patients. Capillary angiogenesis is an important vascular mechanism for adaptation to PH. The overall existence of histopathologic duodenopathy is much higher than that of ED and occurs with a similar prevalence in patients with and without ED.

Bile reflux measurement and its contribution to the severity of reflux esophagitis

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequelae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux to endoscopic severity in patients with GERD and Barrett's esophagus (BE).

MATERIALS AND METHODS

Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to nonerosive reflux disease (NERD), erosive reflux disease (ERD) and BE. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were performed in all patients.

RESULTS

Seventy-one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE, which were suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed the following: 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux alone, 18 (19.8%) had bile reflux alone and 18 patients (19.8%) showed no evidences of abnormal reflux. The percentage of the total time of the bilirubin absorbance > 0.14 in 71 patients with ERD was (8.18+/-11.28%) and in 9 patients with BE was (15.48+/-30.48%), which was significantly greater than that in 11 patients with NERD (4.48+/-8.99%), P<0.05 and P=0.01 respectively. All the BE patients had abnormal esophageal bile reflux (bile alone (3 patients)); and mixed bile and acid (6 patients)); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (alone (13 patients) and mixed bile and acid (31 patients)); meanwhile, 15 of them (21.2%) had abnormal acid exposure alone. Despite 11 patients having NERD, four patients (36.4%) had abnormal esophageal bile reflux and two of them had mixed reflux of bile with acid.

CONCLUSION

We believe that the Bilitec method reliably identifies the presence of bilirubin and quantitatively detects the duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in our GERD patients. Bile reflux either alone or along with acid reflux contributes to the severity of erosive and nonerosive reflux diseases as well as in BE.

Epidemiology of hilar cholangiocarcinoma in Egypt: single center study

BACKGROUND/AIMS

Cholangiocarcinoma is the second most frequent malignant tumor of the liver after hepatocellular carcinoma. The incidence rates of hilar cholangiocarcinoma (CC) vary greatly among different areas of the world, this variation is related to distribution of risk factors. The aim of this work is to study epidemiology and possible risk factors in the North East delta of Egypt.

METHODOLOGY

This study included 440 patients with hilar cholangiocarcinoma who were admitted to the Gastrointestinal Surgical Center, Mansoura University between January 1995 and October 2004. After complete evaluation by thorough history, clinical examination, biochemical assessment including liver function tests, kidney function tests, blood picture and serology of viral markers, tumor markers and radiological investigation.

RESULTS

The mean age was 54.49 +/- 12.8 (range 23 to 82 year). Male to female ratio was 1.7:1, with increasing annual incidence from 22 patients at 1995 up to 68 patients in 2003 and 60 patients in the first 10 months of 2004. Hilar CC is common in patients coming from rural areas especially in Dakahlia government area (41%). All patients presented with jaundice, while weight loss was presented in 41%, and right upper abdominal pain in 37% of patients. Positive history of schistosomiasis infection was encountered in 66.5% while typhoid infection was in 52% of patients with high prevalence of both in rural versus urban (89% vs. 13%, p < 0.001 & 66% vs. 25%, p < 0.001). Laboratory assessment revealed 238 (54%) patients HCV positive while HBs antigen positive in 10 (2%) with high significant increase of HCV in rural versus urban (70% vs. 16%, p < 0.001). Gallstones was significantly higher in rural versus urban (28% vs. 40%, p = 0.016). The laboratory data showed highly significant increase in serum alkaline phosphatase, CA19.9 (26.9 +/- 1 4.4mg/dL, 56.3 +/- 30.6 KAU, 517.8 +/- 279.2 u/mL respectively).

CONCLUSIONS

We conclude that, the number of newly diagnosed cases increases annually, it is common in males especially in farmers and rural residents. Liver cirrhosis, HCV, bilharziasis, chronic typhoid infection and gallstones can be possible risk factors for hilar cholangiocarcinoma in Egypt.

Evaluation of tumour necrosis factor-alpha, soluble P-selectin, gamma-glutamyl transferase, glutathione S-transferase-pi and alpha-fetoprotein in patients with hepatocellular carcinoma before and during chemotherapy

Hepatocellular carcinoma (HCC) is an environmentally related cancer, with both viral and chemical carcinogens involved in a multistage process. To date, it has been difficult to detect the asymptomatic precursor lesions in early HCC. Therefore, the majority of HCC patients are not amenable to therapy, as they are detected at late stages. To evaluate the significance of tumour necrosis factor-alpha (TNF-alpha), sP-selectin, gamma-glutamyl transferase (GGT), glutathione S-transferase-pi (GST) and alpha-fetoprotein (AFP) in the diagnosis and follow up of HCC patients during chemotherapy with adriamycin, 45 subjects (15 healthy volunteers, 15 with benign liver diseases and 15 HCC patients) are studied before and during chemotherapy (three cycles of intravenous adriamycin). HCC patients had significantly higher serum levels of TNF-alpha, sP-selectin, GGT, GST and AFP Serum levels of GGT and GST were significantly higher in HCC patients with poorly differentiated tumours than in patients with well- and moderately differentiated tumours. Treatment with adriamycin for three cycles produced a significant decrease in TNF-alpha, sP-selectin and GST. Thus, it is concluded that GST is a superior diagnostic indicator and may be a prognostic marker in HCC patients.

Free radical scavenging phenylethanoid glycosides from Leucas indica Linn

A new phenylethanoid glycoside, 2-(3,4-dihydroxyphenyl)-ethyl-O-alpha-L-rhamnopyranosyl-(1 --> 3)-O-alpha-L-rhamnopyranosyl-(1 --> 6)-4-O-E-feruloyl-beta-D-glucopyranoside (3-O-methyl poliu-moside, 1) along with five known phenylethanoid glycosides (2-6) were isolated from the aerial parts of Leucas indica Linn. The structure of compound 1 has been elucidated on the basis of spectral data. Compounds 1-6 exhibited significant antioxidant activity in 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical assay method. These compounds were also found to be moderate inhibitors of xanthine oxidase (XO) enzyme.

Epidemiology of hepatocellular carcinoma in lower Egypt, Mansoura Gastroenterology Center

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) is now regarded as one of the major malignant diseases worldwide, with significant variations in its epidemiology.

OBJECTIVE

study of the epidemiology of hepatocellular carcinoma and its relation to age, sex, residence, and viral hepatitis in Egypt.

METHODOLOGY

From January 1992 to May 2005, 1012 cases with hepatocellular carcinoma were diagnosed in the Gastroenterology Center, Mansoura University, Egypt. All patients were evaluated for age, sex, residence, occupation, history of other medical disease, anti-bilharzial treatment, blood transfusion, viral markers, and liver functions.

RESULTS

The mean age was 54.26 +/- 9.2, with high prevalence between 51 and 60 years. Male to female ratio was 5:1, farmers constituted 37.6%, workers 22.9% and housewives 12.8% of the patients. The number of HCC patients increases yearly from only 9 patients evaluated at 1992 to 80 patients in the first 5 months of the year 2005. The mean age increased from 45 years at 1992 up to 58 years at year 1996. Seventy-seven percent of the patients were resident in rural areas versus 23% in urban areas. Seventy-eight percent of patients presented with abdominal pain, 7.1% with abdominal swelling, 4.3% with jaundice, 2.4% with other symptoms and 8.8% of the HCCs were discovered accidentally. The prevalence of diabetes mellitus among HCC patients was 13.6%, history of anti-bilharzial treatment was positive in 37.6%. Hepatitis C, B and mixed B&C was 76.6%, 3.3%, 3.6% respectively. History of blood transfusion was encountered in only 10.6%. Twenty-seven percent of HCC patients had previous history of surgery. Clinical and laboratory studies revealed that, 52.1% of patients were Child's A, 37.3% B and 10.7% C. Tumor size >5 cm in 65.5%, the right lobe was the site in 63.9%, left lobe in 25.8% and both lobes in 10.3% of the patients. Lesions were single in 71.1%, multiple in 24.9% and diffuse in 4% of cases. Portal vein thrombosis was detected in 15.9%. Hepatic resection was done in 25.8%, chemoembolizations in 17.2%, radiofrequency in 13.1%, alcohol injection in 0.9%, mixed treatment in 3.5% of patients while 38.7% were managed by conservative treatment due to no available safe treatment.

CONCLUSIONS

The number of newly diagnosed patients with HCC increases annually. The prevalence of HCC is high in Nile Delta area, and is more common in males, rural residents and farmers especially in HCV patients. In rural areas there are other risk factors that may be responsible for this high incidence, such as pollution, aflatoxins and use of insecticides, which need more study.

Phosphodiesterase-I inhibitor quinovic acid glycosides fromBridelia ndellensis

Quinovic acid-3-O-alpha-L-rhamnopyranoside (1), quinovic acid-3-O-beta-D-fucopyranoside (2), quinovic acid-3-O-beta-D-glucopyranosyl (1 --> 4)-beta-D-fucopyranoside (3), methyl gallate (4) and ethyl gallate (5) were isolated from the ethyl acetate extract of Bridelia ndellensis barks by fractionation. Compounds 1-3 showed significant inhibitory activity against snake venom phosphodiesterase-I.

Hypertensive lower esophageal sphincter (HLES): prevalence,symptoms genesis and effect of pneumatic balloon dilatation

SUMMARY AND BACKGROUND DATA

The Hypertensive lower esophageal sphincter (HLES) is an unusual primary motor disorder of the esophagus. The significance of this motility disorder is still questionable.

OBJECTIVE

The objectives were: (a) identification of the prevalence of HLES in these patients, (b) identification of the common presenting symptoms of HLES, (c) study of the correlation of the symptoms with LESP and (d) study of the effectiveness of pneumatic balloon dilation in cases that fail to respond to medical treatment.

METHODS

A retrospective study that includes four thousand one hundred and seventy patients, who were subjected to esophageal manometry in the period from January 1994 to December 2003, among whom sixty-six patients with HLES (LESP> 40 mmHg) were found. In addition to manometry, upper endoscopy was done to forty-nine patients, upper GI barium studies to thirty-eight patients and esophageal pH- metry to sixteen patients.

RESULTS

showed that most of our patients were females (45 females and 21 males), with a mean age of 36.6 +/- 14 years. Patients with dysphagia (57.5%) had the highest LESP (52.1 +/- 21, mmHg) while patients with chest pain (47%) had the highest distal esophageal contraction amplitude (153.9 +/- 93.2 mmHg). Endoscopy showed varying degrees of esophagitis in 17 patients (34%). Barium studies showed corkscrew esophagus in seven patients (18.4%) and dilated esophagus in nine patients (23.7%). LESP was highest in patients with dilated esophagus (57.5 +/- 33.4 mmHg). All our patients were subjected to medical treatment, of which twelve patients underwent pneumatic dilation with successfully reduced LESP and symptoms relief in 91% of patients.

CONCLUSIONS

It was concluded that the prevalence of HLES is around 1.6, in which dysphagia and chest pain are the usual presenting symptom, and that pneumatic balloon dilatation is very effective when properly applied. It will probably occupy the same position it has in achalasia.