Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee

Wernicke's encephalopathy after laparoscopic cardiomyotomy for achalasia

Achalasia is an incurable neuromuscular disorder of the esophagus, resulting from destruction of the esophageal myenteric plexus. This leads to aperistalsis and failure of the lower esophageal sphincter to relax after swallowing. Symptoms of achalasia are gradual in onset and include dysphagia, regurgitation, and weight loss. Severe malnutrition can ensue. Wernicke's encephalopathy (WE) is a serious, potentially fatal, neurologic disorder caused by thiamine deficiency (vitamin B(1)), classically described as presenting with a triad of ocular abnormalities, ataxia, and confusion. The incidence is uncertain, and many cases likely go unrecognized. It is usually diagnosed in the alcoholic population. We describe its onset after the successful surgical treatment of achalasia.

Persisting symptoms and decreased health-related quality-of-life in a cross-sectional study of treated achalasia patients

BACKGROUND

Little is known about symptom characteristics of treated achalasia patients and their effect on health-related quality-of-life (HRQoL).

AIMS

To examine clinical remission, achalasia-associated symptoms and HRQoL in treated achalasia patients.

METHODS

The Eckardt clinical symptom score, RAND-36 and a disease-specific HRQoL questionnaire were sent to 171 treated achalasia patients.

RESULTS

76.6% of the patients returned their questionnaire. 44.9% of them were not in symptomatic remission. Prevalence of frequent dysphagia (at least daily) and chest pain (at least weekly) was 46% and 38%, respectively. Achalasia patients had lower general HRQoL scores than control subjects (all RAND-36 subscales, except health change; P < or = 0.002). Patients with frequent symptoms of chest pain and dysphagia showed lower HRQoL than patients with less frequent symptoms on three RAND-36 subscales (pain, social functioning and general health perceptions; P < 0.003). Patients in clinical remission showed higher HRQoL than patients who were not, however HRQoL in the 'remission group' remained significantly impaired as compared to controls (all RAND-36 subscales except emotional role limitations and mental health; P < 0.001).

CONCLUSIONS

Many achalasia patients remain severely symptomatic after treatment and have decreased HRQoL. Frequent symptoms are associated with lower HRQoL. Patients in clinical remission show substantially improved, but not restored HRQoL.

Is aperistalsis with complete lower esophageal sphincter relaxation an early stage of classic achalasia?

BACKGROUND

Aperistalsis with complete lower esophageal sphincter (LES) relaxation, characterized by the complete relaxation of the LES and aperistalsis of the esophageal body on manometry, has been considered by some authors to be an early manifestation of classic achalasia, which is defined as incomplete relaxation of the LES and aperistalsis of the esophageal body. The aim of the present study was to compare the clinical features of patients with aperistalsis with complete LES relaxation, with those of patients with classic achalasia.

METHODS

Eighteen patients with aperistalsis with complete LES relaxation and 53 patients with classic achalasia were analyzed with regard to clinical history, the maximal diameter of the esophageal body on barium esophagogram, LES resting pressure and the duration of LES relaxation on manometric recordings, and the selected treatment and its efficacy.

RESULTS

The aperistalsis with complete LES relaxation group had distinctly different features compared to those of the classic achalasia group including older age, more frequent association with non-cardiac chest pain, less frequent association with dysphagia and weight loss, lower LES resting pressures, and longer duration of LES relaxation. However, the two groups were similar in terms of maximal diameter of the esophageal body, and efficacy associated with pneumatic dilation.

CONCLUSIONS

Aperistalsis with complete LES relaxation on manometry is not necessarily an early manifestation of classic achalasia. However, this condition does not preclude a diagnosis of achalasia or a good response to achalasia therapy.

Endoscopic pneumatic dilation in treatment of achalasia: an analysis of 81 cases

AIM: To investigate the efficacy of endoscopic pneumatic dilation (EPD) in the treatment of achalasia of cardia (AC).

METHODS: A total of 81 AC patients with achalasia of cardia were treated with endoscopic pneumatic dilation. Then the clinic symptoms were observed, and gastroscopy and X-ray examination were performed to evaluate the therapeutic efficacy.

RESULTS: The remission rate for dysphagia was 100%. No perforation or other serve complications occurred. The reexaminations of gastroscopy and X-ray indicated that the symptoms were improved obviously in comparison with those before EPD treatment. After following up for about 0.5 to 5 years, no one recurred.

CONCLUSION: EPD is effective, safe, and economical in the treatment of AC with less suffering, and it is the ideal choice to treat AC.

Achalasia and thyroid disease

AIM: To investigate some possible etiologies of achalasia by screening patients with achalasia for some autoimmune diseases such as thyroid disease.

METHODS: We examined 30 known cases of achalasia (20 females, 10 males). Their age ranged 15-70 years. All of them were referred to our institute for treatment. Their sera were evaluated to detect some possible associations with rheumatoid disease, thyroid disease, inflammatory process, anemia, etc.

RESULTS: Seven out of 30 patients (23%) had thyroid disease including four patients with hypothyroidism (13.3%), two patients with hyperthyroidism (6.6%), and one had only thyroid nodule but was in euthyroid state (3.3%). Two of these hypothyroid patients had no related clinical symptoms (subclinical) and two had clinical manifestations of hypothyroidism. There were no correlations between the intensity of thyroid diseases and the severity of achalasia symptoms.

CONCLUSION: The etiology of achalasia is unknown although autoimmunity has been implicated and is supported by several studies. Thyroid disease presents concomitantly with achalasia in about one fourth of our patients who may have a common etiology.

Surface area: a better predictor of disease severity than the height and volume of the barium column in patients with primary achalasia

OBJECTIVE

Subjective assessment of primary achalasia is not accurate. We aimed to study the utility of surface area of barium retention in the objective assessment of these patients.

METHODS

Subjective and objective esophageal functions of 99 patients with primary achalasia were evaluated initially and 43 of them were reevaluated 1 month after balloon dilation.

RESULTS

Before dilation: Ninety-nine patients were enrolled. Forty-one of them were male. The mean age was 37.5+/-15.3 years. The mean score, resting lower esophageal sphincter pressure, height, surface and volume of barium retention at 5 min were 8.03+/-3.1, 59.1+/-20 mmHg, 9.9+/-4.9 cm, and 23.6+/-13.9 cm and 53.2+/-47.7 cm, respectively. Surface area at 5 min had best correlation and predictive value for resting lower esophageal sphincter pressure. After dilation: Forty-three of 99 patients were reevaluated after balloon dilation. The mean age was 36.8+/-13.6 years. Seventeen of them were male. Mean score, resting lower esophageal sphincter pressure, height, surface area and volume of barium retention at 5 min dropped significantly after dilation. Surface area at 5 min had best correlation and predictive value for lower esophageal sphincter pressure.

CONCLUSIONS

Surface area of barium retention at 5 min is an accurate objective tool to assess patients with primary achalasia. It is cheap and easy to perform; therefore, it could be used more frequently in postdilation follow-up.

Review article: the management of achalasia - a comparison of different treatment modalities

BACKGROUND

Achalasia is an uncommon primary oesophageal motor disorder with an unknown aetiology. Therapeutic options for achalasia are aimed at decreasing the lower oesophageal sphincter pressure, improving the oesophageal empting, and most importantly, relieving the symptoms of achalasia. Modalities for treatment include pharmacologic, endoscopic, pneumatic dilatation and surgical. The decision of which modality to use involves the consideration of multiple clinical and economic factors.

AIM

To review the management strategies currently available for achalasia.

METHODS

A Medline search identified the original articles and reviews the published in the English language literature between 1966 and 2006.

RESULTS

The results reveal that pharmacotherapy, injection of botulinum toxin, pneumatic dilatation and minimally invasive surgical oesophagomyotomy are variably effective at controlling the symptoms of achalasia but that each modality has specific strengths and weaknesses which make them each suitable in certain populations. Overall, pharmacologic therapy results in the shortest lived, least durable response followed by botulinum toxin injection, pneumatic dilatation and surgery, respectively.

CONCLUSION

The optimal treatment for achalasia remains an area of controversy given our lack of complete understanding about the pathophysiology of the disease as well as the high numbers of clinical relapse after treatment. Further research focusing on optimal dosing of botulinum toxin injection and optimal timing of repeated graduated pneumatic dilatations could add to our knowledge regarding long-term therapy.

Comparison of esophageal motility impairment caused by Chagas' disease in two age groups

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean ± SE: 30.8 ± 4.3 mm Hg) than younger patients (51.9 ± 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41%) and fewer peristaltic (8%) contractions than younger patients (non-conducted: 16%, peristaltic: 21%). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.

The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia

BACKGROUND & AIMS

Studies comparing long-term success after pneumatic dilatation (PD) and laparoscopic Heller myotomy (HM) are lacking. This study compares long-term outcome of PD (single dilatation and graded approach) and laparoscopic HM and identifies risk factors for treatment failure.

METHODS

A cross-sectional follow-up evaluation of an achalasia cohort treated between 1994 and 2002 was followed-up for a mean of 3.1 years. There was a total of 106 patients treated by graded PD (1-3 dilatations with progressively larger balloons) and 73 patients treated by HM (20 had failed graded PD and crossed over to HM). A symptom assessment (structured telephone interview or clinic visit) was performed and patients were given freedom from alternative therapies to determine treatment outcome. Endoscopy, manometry, and timed barium esophagram were performed to determine the cause of treatment failure.

RESULTS

The success of single PD was defined as freedom from additional PDs: 62% at 6 months and 28% at 6 years (risk factors for failure: younger age, male sex, wider esophagus, and poor emptying on posttreatment timed barium esophagram). Freedom from subsequent PDs increased with each dilatation (graded PD). The success of graded PD and HM, defined as dysphagia/regurgitation less than 3 times/wk or freedom from alternative treatment, was similar: 90% vs 89% at 6 months and 44% vs 57% at 6 years (no risk factors for failure were identified). Causes of symptom recurrence were incompletely treated achalasia (96% after PD vs 64% after HM) and gastroesophageal reflux disease (4% after PD vs 36% after HM).

CONCLUSIONS

No treatment cures achalasia. Short- and long-term success is similar for graded PD and laparoscopic HM. Therapeutic success decreases steadily over time. Achalasia patients need careful long-term follow-up evaluation.

The relationship between gastro-oesophageal reflux symptoms and achalasia

BACKGROUND AND AIMS

Patients with achalasia can experience heartburn, which may be misinterpreted as gastro-oesophageal reflux disease (GORD), leading to a delay in diagnosis and subsequent treatment. We investigated the relationship between gastro-oesophageal reflux (GOR) and reflux symptoms in a large cohort of patients with achalasia.

METHODS

The symptoms of all patients with a manometric diagnosis of achalasia made over the past 15 years were studied. The types of treatment, onset and pattern of heartburn, lower oesophageal sphincter pressure (LOSP) and 24-h oesophageal pH studies were compared.

RESULTS

A total of 110 out of 225 untreated (48.9%) and 57 out of 99 treated (57.6%) patients experienced heartburn. An oesophageal pH study was performed on 80 patients and GOR was found in only six out of 57 untreated (10.5%) and 10 out of 23 treated (43.5%) patients. A low LOSP (<10 mmHg) was associated with an increased risk of GOR [odds ratio (OR) 14.2; 95% confidence interval (CI) 1.6-128.7; P<0.02). Treated patients were also more likely to develop GOR (OR 7.9; 95% CI 2.0-32.1; P<0.005). Neither the LOSP nor previous treatment was, however, a predictor of heartburn. The timing of the onset of dysphagia and heartburn was categorized in 111 patients. There was no significant difference in mean (or median) LOSP between these three groups, indicating that the LOSP is unlikely to predict the occurrence of symptoms.

CONCLUSIONS

Heartburn is common in patients with untreated and treated achalasia, but is a poor predictor of GORD. Such patients should always be investigated with a 24-h oesophageal pH study to clarify the presence of GORD.

Prevalência, classificação e características do refluxo cecoileal diagnosticado pelo enema opaco

OBJETIVO: Verificar, retrospectivamente, a prevalência do refluxo cecoileal diagnosticado pelo enema opaco, caracterizar sua distribuição etária e sexual e classificá-lo conforme o grau de intensidade. MATERIAIS E MÉTODOS: Foram revistos 715 enemas opacos, incluindo 268 homens e 447 mulheres com idade média de 54 anos. RESULTADOS: Dos 715 casos examinados, 46,5% apresentaram refluxo cecoileal, sendo 45% do tipo leve, 37,5% do tipo moderado e 17,5% do tipo severo. Refluxo cecoileal esteve presente em 48,3% das mulheres e em 43,6% dos homens. A distribuição percentual do refluxo cecoileal por faixa etária mostrou 46,1% nos indivíduos com menos de 21 anos, 42,1% nos indivíduos entre 21-40 anos, 49,8% nos indivíduos entre 41-60 anos e 44,7% nos indivíduos com mais de 60 anos. CONCLUSÃO: Refluxo cecoileal foi achado relativamente freqüente em nosso material, correspondendo os graus moderado e severo a 25% do material examinado. Aparentemente, não há associação entre seu surgimento e sexo ou idade. A etiopatogenia e conseqüências do refluxo cecoileal são ainda pouco conhecidas. Alguns estudos sugerem que o comprometimento de componentes da junção ileocecal, como os ligamentos, pode favorecer seu aparecimento. Entre as conseqüências prováveis, incluem-se a contaminação e alteração motora ileais, resultantes do material refluído do ceco.

Modern management of achalasia

The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.

Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia

BACKGROUND

Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery.

METHODS

The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire.

RESULTS

Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%).

CONCLUSION

Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.

Achalasia in a patient with gastroesophageal varices: problematic treatment decisions

The coexistence of achalasia and gastroesophageal varices has been reported sporadically in the English medical literature. We report the case of a 60-year-old Hispanic woman with cryptogenic cirrhosis who was referred for a liver transplant evaluation and subsequently developed progressive dysphagia to both solids and liquids as well as substernal chest pain and weight loss. Endoscopy revealed the presence of grade I esophageal varices and large fundic varices, as well as retained liquid and solid food in the distal esophagus. Radiographic and manometric studies were consistent with achalasia. After botulinum toxin (Botox) injections were no longer effective a transjugular intrahepatic portosystemic shunt was performed for portal decompression before proceeding with pneumatic dilation. Optimal treatment of these 2 conditions, when they occur simultaneously, is problematic. We discuss this patient's management and our approach to this infrequent combination of diseases.

Myotomy: follow-up study of 50 patients

Laparoscopic myotomy has become the standard treatment for definitive management of achalasia. This study was undertaken to assess the long-term results of the procedure. Perioperative data, including a symptom score questionnaire, were collected prospectively on all patients undergoing laparoscopic myotomy. The same questionnaire was readministered by phone to patients with follow-up greater than 3.75 years. The long-term success of myotomy was defined as a 50% or greater decrease in the dysphagia score and absence of further therapy (responders). Fifty of 95 patients (age = 57 years, 23 females) were successfully contacted. Average follow-up was 6.2 years. The overall long-term success rate was 64% (responders). Forty-two patients (84%) were able to gain or maintain their weight after the procedure. Five patients (10%) required one or more endoscopic dilations after the myotomy. The mean change in dysphagia score was higher in the responder group (7.8 +/- 1.9 vs. 1.9 +/- 2.1; P = 0.001). The two groups were similar in terms of age, gender distribution, and follow-up interval (P > .05). Dor fundoplication was performed in six patients (12%), and the outcome comparisons of these patients showed no significant differences from those patients undergoing Heller alone. Overall satisfaction was achieved in 94% of contacted patients. These results confirm that laparoscopic myotomy is an effective procedure with excellent long-term symptom resolution and overall satisfaction in patients with achalasia.

Esophageal contractions in Chagas' disease and in idiopathic achalasia

GOALS

The aim of this study was to compare the esophageal contractions in Chagas' disease and in idiopathic achalasia.

BACKGROUND

It is suggested that the esophageal involvement caused by Chagas' disease and by idiopathic achalasia, although similar, shows some differences.

STUDY

We studied the contractions at 2, 7, 12, and 17 cm below the upper esophageal sphincter in 25 patients with idiopathic achalasia (15 with dilatation), 52 with Chagas' disease (22 with dilatation), and 18 controls. Each subject performed 5 swallows of a 5-mL bolus of water alternated with 5 dry swallows.

RESULTS

In the distal esophageal body, the amplitude was lower in patients than in controls. Among patients with esophageal dilatation, the proximal amplitude was lower in patients with idiopathic achalasia, and the time interval between the contractions at 2 and 7 cm was longer in patients with Chagas' disease, the number of failed contractions was higher in Chagas' disease, and simultaneous contractions were more frequent in idiopathic achalasia. The simultaneous isobaric pressure in the distal esophagus was associated with an increase in proximal pressure that was higher than distal but lower than proximal swallowing pressure.

CONCLUSION

The results suggested that idiopathic achalasia and Chagas' disease cause similar impairment of distal esophageal motility, but in patients with esophageal dilatation the impairment of proximal motility may be not the same.

Lower oesophageal sphincter pressure and timed barium oesophagogram: two objective parameters in the non-invasive assessment of primary achalasia

BACKGROUND

The non-invasive assessment of primary achalasia is not precise.

AIM

To compare investigations before and 1 month after balloon dilation in achalasia.

METHODS

Fifty-two patients with primary achalasia were enrolled. Subjective and objective variables of oesophageal functions were analysed before and 1 month after balloon dilation.

RESULTS

The mean predilation symptom score, lower oesophageal sphincter pressure, height and volume of barium at 5 min were 7.7 +/- 2.6, 62.0 +/- 25.1 mmHg, 9.2 +/- 6.1 cm and 53.2 +/- 49.8 mL respectively; the mean postdilation values were 3.0 +/- 3.0, 34.1 +/- 12.5 mmHg, 7.9 +/- 5.1 cm and 28.0 +/- 30.1 mL respectively. The before dilation volume of barium at 5 min correlates significantly with lower oesophageal sphincter pressure (P < 0.01). The mean symptom scores, lower oesophageal sphincter pressure and volume of barium at 5 min dropped significantly after intervention (P < 0.01), but the reduction in barium height at 5 min was not significant. The percentage changes in volume at 5 min significantly predicted the percentage changes in lower oesophageal sphincter pressure (P < 0.01).

CONCLUSIONS

The volume of barium retention at 5 min can predict the lower oesophageal sphincter pressure before and after balloon dilation in primary achalasia. This could be used as a non-invasive objective tool for initial and post-dilation assessment.

Timing of surgical intervention does not influence return of esophageal peristalsis or outcome for patients with achalasia

BACKGROUND

It has been suggested that abnormal function of the lower esophageal sphincter is the primary abnormality in esophageal achalasia, and that the absence of esophageal peristalsis is secondary to the outflow obstruction caused by the lower esophageal sphincter. Furthermore, it has been proposed that early elimination of the resistance at the level of the gastroesophageal junction by surgical intervention could result in return of esophageal peristalsis. This study aimed to assess whether the timing of surgical intervention affects the return of esophageal peristalsis and the clinical outcome for patients with achalasia.

METHODS

Between January 1991 and May 2003, 173 patients underwent a Heller myotomy by minimally invasive surgery for treatment of esophageal achalasia. Of these patients, 41 (24%) had pre- and postoperative esophageal manometry. These patients were divided into three groups based on the duration of symptoms: group A (10 patients; duration of symptoms 12 months group B (19 patients, duration of symptoms 12 to 60 months), and group C (12 patients; duration of symptoms longer than 60 months).

RESULTS

The average duration of symptoms (dysphagia was present in all patients) was as follows: group A (8 +/- 4 months), group B, (35 +/- 16 months), and group C, (157 +/- 94 months). Vigorous achalasia was present in 40%, 21%, and 17% of the groups respectively. The differences between the groups were not significant. Postoperatively, improvement in esophageal motility was seen in no patient in group A, 1 patient (5%) in group B, and 1 patient (8%) in group C. Excellent or good results were obtained for 90% of the group A patients, 95% of group B patients, and 92% of the group C patients. Again, the differences were not significant.

CONCLUSIONS

The results show that: a) the presence of vigorous achalasia is independent of symptoms duration; b) the timing of surgical intervention does not influence the return of peristalsis; and c) the results of a Heller myotomy are independent of symptoms duration.

Achalasia with Complete Relaxation of Lower Esophageal Sphincter: Radiographic-Manometric Correlation

PURPOSE

To evaluate retrospectively the presence of complete relaxation of the lower esophageal sphincter (LES) at manometry in patients with achalasia depicted on barium esophagograms.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and did not require informed consent. A search of radiology and manometry records identified 21 patients (12 men, nine women; mean age, 52.4 years) with achalasia depicted on barium esophagograms who had undergone manometric examinations and met the inclusion criteria. Radiologic reports and images were reviewed for presence or absence of primary peristalsis, impaired LES opening, esophageal dilatation, delayed emptying of barium, and nonperistaltic contractions. Manometry reports were reviewed for presence or absence of peristalsis or simultaneous esophageal contractions. Resting and residual LES pressures were recorded to determine whether LES relaxation was complete or incomplete. Medical records were reviewed to determine clinical presentation and follow-up (treatment and patient course), and radiographic files were reviewed to determine radiographic findings at follow-up examinations. Clinical characteristics (eg, age, dysphagia, and weight loss) were correlated with LES relaxation at manometry. Data were analyzed statistically with Fisher exact and Wilcoxon rank sum testing.

RESULTS

All 21 patients with radiographic findings of achalasia had aperistalsis at manometry. Fourteen patients (67%) had incomplete LES relaxation at manometry during swallowing, and seven (33%) had complete LES relaxation. There were no significant differences between patients with complete LES relaxation and those with incomplete LES relaxation in mean age (P = .59), duration of dysphagia (P = .18), or weight loss (P > .99). Clinical follow-up findings were available for six patients with complete LES relaxation at manometry and 10 with incomplete relaxation. Symptoms resolved after treatment in all six patients with complete LES relaxation. Six (60%) of 10 patients with incomplete LES relaxation had resolution of symptoms after treatment, and four (40%) had substantial improvement.

CONCLUSION

These data suggest that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry. If radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis.

Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy

BACKGROUND

Laparoscopic Heller myotomy (HM) has become an increasingly preferred modality to treat achalasia. However, the treatment course after a failed myotomy is controversial with fears that pneumatic dilation (PD) has high perforation risk.

GOAL

To compare success and safety of graded PD with Rigiflex balloons in achalasia patients without a prior HM (untreated cases) and those with a failed HM.

STUDY

A total of 108 patients were retrospectively evaluated: 96 untreated cases (53 male, 43 female, mean age 51 years) and 12 failed HM(7 male, 5 female, mean age 54 years). Symptoms (dysphagia and regurgitation) and physiologic studies, lower esophageal sphincter pressure (LESP) and timed barium swallow, assessed pre- and post-PD. Success was defined as: 1) symptom improvement to </=2 to 4 times per week, and 2) >/=80% decrease in 5-minute barium column height from initial timed barium swallow.

RESULTS

A total of 139 PDs performed (117 untreated cases, 22 failed HM): 2 perforations in untreated cases and none in failed HM group. Baseline demographics were similar, but failed HM patients had significantly lower LESP and timed barium swallow columns. Despite less LES resistance, failed HM group (symptom and physiologic success: 50% and 10%) did not do as well after PD as compared with untreated cases (symptom and physiologic success: 74% and 52%, respectively). Five failed HM patients had good symptom relief after PD compared with poor responders these patients were older (>50 years) and had LESP >17 mm Hg.

CONCLUSIONS

PD perforation risk is not higher after HM. Despite lower LES pressure, patients undergoing PD after failed HM do not do as well as untreated cases. Factors predicting better outcome include older age and higher LES pressure.

Impedance characteristics of esophageal motor function in achalasia

Detailed data on patterns of esophageal bolus transport in patients with achalasia are still lacking. To study these we applied the novel technique of multichannel intraluminal impedance measurements. Ten patients with achalasia were studied using a 16 channel system. Liquid and semisolid boluses of 10 mL were applied with the patients in a supine position. Patterns of bolus transport were determined and analyzed as compared to results obtained from 20 healthy subjects. The healthy subjects featured a unique typical primary peristalsis pattern independent of bolus viscosity. In contrast, achalasia patients demonstrated different impedance characteristics, including: (i) significantly lower baseline esophageal impedance during the resting state as compared with healthy volunteers (999 omega +/- 108 versus 2749 omega +/- 113); (ii) failed bolus transport through the esophagus in all cases; (iii) impedance evidence of luminal content regurgitation in 35% of the swallows (iv) impedance evidence of pathological air movement within the proximal esophagus during deglutition in 38% of the swallows, so called air trapping. Thus, impedance characteristics of achalasia have been defined and can be attributed to known symptoms of achalasia. They can be used as basic findings for further classification of pathological bolus transports in other esophageal motility disorders.

Pneumatic dilatation in achalasia of the esophagus: a report from Argentina

We review the treatment of esophageal achalasia by means of pneumatic dilatation (PD), analyzing its results and comparing them with those of the literature. We conclude that our personal experience is similar to that of the literature: PD and surgery produce similar results (67-95%), morbidity (2-9.5%), and mortality (0.7-1%); and PD is cheaper than surgery. According to these conclusions, we believe that the decision of the appropriate treatment should be based on a combination of the choice of the properly informed patient and the operator's experience. However, we also conclude that surgery is mandatory in selected cases, such as achalasia associated with hiatus hernia, esophageal diverticula and neoplasia, history of previous PD failure (since in our experience the results after a second PD are very poor), postoperative relapse, and patients with grade IV mega-esophagus according to Resano-Malenchini's classification.

Behandlung der Achalasie

Achalasia is a condition of unknown etiology. It represents a motor disorder of the esophagus characterized by absent or incomplete relaxation of the lower esophageal sphincter upon swallowing and by non-propulsive swallow-induced contraction waves or amotility of the esophageal body. Dysphagia and regurgitation of ingesta are the most frequent symptoms. Medical treatment, i.e. by calcium-channel blockers and nitric oxide donors, may be tried in patients with mild dysphagia or in elderly patients but rarely yields adequate symptom relief. Mechanical dilatation of the achalasic sphincter may be performed as an initial treatment option. Intrasphincteric injections of botulinum toxin seemed to be a promising alternative, but it has become obvious that, in most cases, repeated applications of the toxin are required to maintain patients symptom-free. Myotomy of the achalasic sphincter with or without fundoplication to prevent gastroesophageal reflux, is employed mainly in patients in whom dilatations have failed, but since the introduction of minimally invasive surgery, myotomy has become the primary treatment at many centers. This article aims to provide an overview of the development of the conservative and surgical treatment of achalasia.

Preoperative lower esophageal sphincter pressure has little influence on the outcome of laparoscopic Heller myotomy for achalasia

BACKGROUND

It is believed that in untreated patients with achalasia, the lower esophageal sphincter (LES) is almost always hypertensive and a Heller myotomy resolves symptoms by decreasing the LES pressure. The incidence of a normal or hypotensive LES in untreated achalasia patients is unknown. The goals of this study were to determine the incidence of a normal or hypotensive LES in untreated achalasia patients and the outcome of laparoscopic Heller myotomy in achalasia patients with either normal or low LES pressure.

METHODS

Between January 1990 and May 2002, a diagnosis of achalasia was made in 239 patients. Among 109 patients (46%) who had not previously received any form of treatment, 53 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Based on the preoperative LES pressure (normal, 14-24 mmHg) they were divided into three groups: group A--four patients (7.5%), LES pressure <14 mmHg; group B--18 patients (34%), LES pressure 14-24 mmHg; and group C-31 patients (58.5%), LES pressure >24 mmHg.

RESULTS

Among the 109 untreated patients, the LES was hypertensive in 49 patients (45%), normal in 29 patients (27%), and hypotensive in 31 patients (28%). The clinical outcome was good among the three groups of patients who underwent laparoscopic Heller myotomy, with poor outcome in only approximately 10% in each group.

CONCLUSIONS

These data show that in 55% of untreated. achalasia patients the LES pressure is either normal or low, and that laparoscopic Heller myotomy usually relieves symptoms regardless of preoperative LES pressure.

Comparative observation on different intervention procedures in benign stricture of gastrointestinal tract

AIM: To determine the most effective intervention procedure by evaluation of mid and long-term therapeutic efficacy in patients of stricture of the gastrointestinal tract (GIT).

METHODS: Different intervention procedures were used to treat benign stricture of GIT in 180 patients including pneumatic dilation (group A, n = 80), permanent (group B, n = 25) and temporary (group C, n = 75) placement of expandable metallic stents.

RESULTS: The diameters of the strictured GIT were significantly greater after the treatment of all procedures employed (P < 0.01). For the 80 patients in group A, 160 dilations were performed (mean, 2.0 times per patient). Complications in group A included chest pain (n = 20), reflux (n = 16), and bleeding (n = 6). Dysphagia relapse occurred in 24 (30%) and 48 (60%) patients respectively during 6-and-12 momth follow-up periods in group A. In group B, 25 uncovered or partially covered or antireflux covered expandable metallic stents were placed permantly, complications included chest pain (n = 10), reflux (n = 15), bleeding (n = 3), and stent migration (n = 4), and dysphagia relapse occurred in 5 (20%) and 3 patients (25%) during the 6- and -12 month follow-up periods, respectively. In group C, the partially covered expandable metallic stents were temporarily placed in 75 patients and removed after 3 to 7 days via gastroscope, complications including chest pain (n = 30), reflux (n = 9), and bleeding (n = 12), and dysphagia relapse occurred in 9 (12%) and 8 patients (16%) during the 6-and-12 month follow-up periods, respectively. The placement and withdrawal of stents were all successfully performed. The follow-up of all patients lasted for 6 to 96 months (mean 45.3 ± 18.6 months).

CONCLUSION: The effective procedures for benign GIT stricture are pneumatic dilation and temporary placement of partially-covered expandable metallic stents. Temporary placement of partially-covered expandable metallic stents is one of the best methods for benign GIT strictures in mid and long-term therapeutic efficacy.

Cost-assessment of alternative management strategies for achalasia

Achalasia is a primary oesophageal motor disorder characterised by the abnormal relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. It is a rare disease, with an estimated incidence of approximately 1/100,000 and a prevalence close to 10/100,000 [1]. Its exact aetiology remains unknown. Autoimmune, infectious, degenerative and hereditary processes have all been proposed as factors that lead to a chronic inflammatory response in the myenteric plexus, thus resulting in selective loss of inhibitory neurons [2] and failure of the LES to relax and aperistalsis in the body of the oesophagus. The most common symptoms of achalasia are dysphagia for solids and liquids, regurgitation, chest pain, weight loss and heartburn in > 90 approximately 75, 40 - 50, approximately 60, approximately 40%, respectively [3,4]. The diagnosis is based on symptoms, barium swallow and manometry. A barium oesophagram typically shows a dilated oesophagus that tapers into a 'bird-beak' at the gastro-oesophageal junction with lack of normal peristalsis on fluoroscopic evaluation. The characteristic manometric features of achalasia are abnormal LES relaxation and aperistalsis; additionally, the LES pressure is frequently high, but can also be normal. Current practice of medicine is faced with rising healthcare costs and limited budgets [5]. We are therefore confronted with an increasing demand to justify the value of our therapeutic interventions, not only from the risk/benefit standpoint but also from the cost perspective [6,7].

Motility disorders. Diagnosis and treatment for the pediatric patient

Motility disorders are common in children and may affect any area of the GI tract. The past decade has brought significant advances in the understanding of motility disorders in pediatrics. More sophisticated testing techniques have helped to differentiate normal from abnormal motility in children of different ages. Manometry now may be used to clarify the pathophysiologic defect underlying chest pain, dysphagia, rumination, gastroparesis, chronic intestinal pseudo-obstruction, and colonic neuromuscular disorders. Motility testing also may be used to identify the motor defect responsible for persistence of symptoms after surgery for GER or HD. New investigational techniques and prokinetic agents likely to be available in the future also were discussed.

Long-term follow-up of achalasia patients treated with botulinum toxin

AIMS

To evaluate long-term efficacy of intrasphincteric injection of botulinum toxin in untreated achalasia patients; to analyse whether age can be a predictor of response; and to verify whether any objective measurements correlate with symptom relief

MATERIALS AND METHODS

A total of 37 patients (mean age 61.4+/-17.5 years) were enrolled, all of whom injected endoscopically with 100 U of botulinum toxin. Symptom score, oesophageal manometry and oesophageal radionuclide emptying were assessed prior to treatment and 4 weeks, 3 months and 1 year after botulinum toxin. In the case of failure or relapse (symptom score >2), treatment was repeated.

RESULTS

All but 6 patients (83.7%) were in clinical remission one month after botulinum toxin. At 12 months, mean symptom score was 0.9+/-0.5 (p<0.05 vs basal); mean lower oesophageal sphincter pressure was 22.0+/-6.3 (p<0.05 vs basal), and 10-min radionuclide retention was 14.0%+/-7.2 (p<0.05 vs basal). Of the 35 patients followed, 12 (34.3%) had a relapse and were re-treated; 4 out of 12 did not respond after re-treatment. Efficacy of first injection of botulinum toxin lasted for a mean period of 15.6 months (range 2-30). Up to day 31 (83.7%) patients were still in remission. We observed a trend towards a better response to botulinum toxin treatment in patients over 50 years (p=0.053). Moreover no correlation was found between any objective achalasia measurements and symptom relief (r coefficient between 0.1 and 0.5)

CONCLUSIONS

Results show that: 1) one or two intrasphincteric injections of botulinum toxin result in clinical and objective improvement in about 84% of achalasia patients and are not associated with serious side-effects; 2) patients over 50 years showed better benefit than younger patients; 3) no correlation was found between any objective measurements and symptom relief.

Oesophageal motility disorders

Oesophageal motility disorders comprise various abnormal manometric patterns which usually present with dysphagia or chest pain. Some, such as achalasia, are diseases with a well defined pathology, characteristic manometric features, and good response to treatments directed at the pathophysiological abnormalities. Other disorders, such as diffuse oesophageal spasm and hypercontracting oesophagus, have no well defined pathology and could represent a range of motility changes associated with subtle neuropathic changes, gastro-oesophageal reflux, and anxiety states. Although manometric patterns have been defined for these disorders, the relation with symptoms is poorly defined and the response to medical or surgical therapy unpredictable. Hypocontracting oesophagus is generally caused by weak musculature commonly associated with gastro-oesophageal reflux disease. Secondary oesophageal motility disorders can be caused by collagen vascular diseases, diabetes, Chagas' disease, amyloidosis, alcoholism, myxo-oedema, multiple sclerosis, idiopathic pseudo-obstruction, or the ageing process.

Esophageal disorders in the elderly

As the number of elderly in the population increases, decompensation of swallowing and airway protective mechanisms can create an increased health care burden. This article outlines the effect of aging on deglutitive function and esophageal and aerodigestive reflexes. Specific disorders in the elderly are discussed.

Manometric heterogeneity in patients with idiopathic achalasia

BACKGROUND & AIMS

In certain cases of achalasia, particularly those in early stages with minimal endoscopic or radiographic abnormalities, the diagnosis may rely on manometry, which is the most sensitive test for the disease. The aim of this study was to critically evaluate the manometric criteria in a population of patients with idiopathic achalasia.

METHODS

Clinical histories and manometric recordings of 58 patients with idiopathic achalasia and 43 control subjects were analyzed with regard to esophageal body contraction amplitude, peristaltic effectiveness in terms of both completeness and propagation velocity, lower esophageal sphincter (LES) resting pressure, LES relaxation pressure, and intraesophageal-intragastric pressure gradient. Variants of achalasia were defined by finding manometric features that significantly differed from the remainder of achalasia patients, such that the diagnosis might be questioned.

RESULTS

Four manometrically distinct variants were identified. These variants were characterized by (1) the presence of high amplitude esophageal body contractions, (2) a short segment of esophageal body aperistalsis, (3) retained complete deglutitive LES relaxation, and (4) intact transient LES relaxation. In each instance, the most extreme variant is discussed and compared with the remainder of the achalasia population and with controls.

CONCLUSIONS

The significance in defining these variants of achalasia lies in the recognition that these sometimes confusing manometric findings are consistent with achalasia when combined with additional clinical data supportive of the diagnosis. Furthermore, such variants provide important clues into the pathophysiology of this rare disorder.

Achalasia

The optimal treatment of achalasia includes several options and presents a challenge for most gastroenterologists. There are numerous patient variables that must be assessed including age, degree of symptoms, duration of disease, desires of each patient, and related comorbidities. Treatment includes both medical and surgical options, with medical therapy further subclassified into pharmacologic and pneumatic dilation. Pneumatic dilations with a polyethylene dilator (sizes of 3.0, 3.5, and 4.0 cm) and laparoscopic myotomy represent the most common forms of therapy. A graduated increase in dilator size, based on symptomatic response, minimizes complications and is successful in more than 90% of patients. Further dilations or adjustment of pharmacologic therapy should be based on symptoms, weight gain, and a timed barium meal. Referral for myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilations. Most patients responding to botulinum toxin (Botox; Allergan, Irvine, CA) injections will require repeat treatment at 3- to 6-month intervals. Due to cost constraints, Botox therapy should be reserved for patients who are at an increased risk from possible complications of a dilation or surgery, or those with less than 2 years of life expectancy. The most cost-effective course of therapy per patient cured over a 5-year period is pneumatic dilation, then Botox, and finally laparoscopic myotomy.

Noncardiac (Unexplained) Chest Pain

Noncardiac (unexplained) chest pain may be caused by esophageal disorders, psychiatric problems, or visceral hypersensitivity of unknown etiology. The most treatable etiologies, in order of their frequency, include gastroesophageal reflux disease (GERD), panic disorders, visceral hypersensitivity (ie, the irritable esophagus), and achalasia. Ensure the diagnosis is correct, and exclude important cardiac disease. In the younger patient, this may require an EKG, stress test, and echocardiogram, while older patients will need coronary angiography. Reassure the patient that there is no evidence of serious disease, and discuss the prognosis.

Management of idiopathic achalasia: short-term and long-term outcomes

This article reviews current trends in management of esophageal achalasia, highlighting short-term outcome and cost comparisons of three treatments: botulinum toxin injection, pneumatic dilation, and laparoscopic myotomy. The quality of life resulting from these palliative treatments is also discussed, as are long-term outcomes.