Gallbladder function and gastric liquid emptying in achalasia

Cardiovascular dysautonomia in Achalasia Patients: Blood pressure and heart rate variability alterations

Achalasia is a disease characterized by the inability to relax the esophageal sphincter due to a degeneration of the parasympathetic ganglion cells located in the wall of the thoracic esophagus. Achalasia has been associated with extraesophageal dysmotility, suggesting alterations of the autonomic nervous system (ANS) that extend beyond the esophagus. The purpose of the present contribution is to investigate whether achalasia may be interpreted as the esophageal manifestation of a more generalized disturbance of the ANS which includes alterations of heart rate and/or blood pressure. Therefore simultaneous non-invasive records of the heart inter-beat intervals (IBI) and beat-to-beat systolic blood pressure (SBP) of 14 patients (9 female, 5 male) with achalasia were compared with the records of 34 rigorously screened healthy control subjects (17 female, 17 male) in three different conditions: supine, standing up, and controlled breathing at 0.1 Hz, using a variety of measures in the time and spectral domains. Significant differences in heart rate variability (HRV) and blood pressure variability (BPV) were observed which seem to be due to cardiovagal damage to the heart, i.e., a failure of the ANS, as expected according to our hypothesis. This non-invasive methodology can be employed as an auxiliary clinical protocol to study etiology and evolution of achalasia, and other pathologies that damage ANS.

Functional dyspepsia and irritable bowel syndrome in patients with achalasia and its association with non-cardiac chest pain and a decreased health-related quality of life

OBJECTIVE

In patients with achalasia, little is known about symptoms of the gastrointestinal tract other than the esophagus. The purpose of this study was to determine the prevalence of two functional disorders, functional dyspepsia (FD) and irritable bowel syndrome (IBS), in a group of treated achalasia patients and to assess the additional impact of these disorders on health-related quality of life (HRQoL).

MATERIAL AND METHODS

Questionnaires assessing the Rome II criteria for FD and IBS together with the Eckardt clinical symptom score and RAND-36 were sent to 171 treated achalasia patients.

RESULTS

Of these patients, 76.6% returned their questionnaires. In the group of achalasia patients, 23% fulfilled the criteria for FD (Dutch general population 13-14%), and 21% fulfilled the criteria for IBS (Dutch general population 1-6%). The prevalence of frequent chest pain (at least weekly) was higher in patients with FD and/or IBS than in those without these symptoms (54.2% versus 28.2%; p=0.004). Female patients with achalasia and with frequent chest pain showed a higher probability of fulfilling the FD and/or IBS criteria (adjusted OR 2.90 (1.18-7.14) and 3.35 (1.4-8.1), respectively; both with p <0.05). Patients fulfilling the FD and/or IBS criteria scored a lower HRQoL on the RAND-36 subscales--pain, social functioning, and vitality--as compared with patients not fulfilling these criteria (p <0.006). CONCLUSIONS; Symptoms of FD and IBS in patients with treated achalasia are common and have a negative impact on HRQoL. Therefore, this has to be included in the standard evaluation of achalasia patients. The association with chest pain suggests a mutual underlying mechanism.

Current clinical approach to achalasia

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and confirmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients’ characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.

Small-volume gallbladders and decreased motility in patients with achalasia

AIM/BACKGROUND

Achalasia may be associated with extraesophageal dysmotility. However, this relation is still poorly understood. In the present study, we used noninvasive real-time ultrasonography to examine the motility function of the gallbladder in the patients with achalasia.

MATERIALS AND METHODS

Thirty-three achalasic patients and 33 healthy volunteers were included in the study. All subjects were investigated after 12 hours of fasting and 30 minutes after a standard test meal. Premeal and postmeal gallbladder volumes were used for calculation of the ejection fraction of the gallbladder and fasting gallbladder volume.

RESULTS

The mean fasting volume (18.52+/-1.45 vs. 24.63+/-1.84 cm; P<0.05) and ejection fractions of gallbladder (35.84+/-4.12 vs. 54.47+/-2.47; P<0.05) in the patients with achalasia were lower than the control group.

CONCLUSIONS

Such a finding may confirm the possible extraesophageal extension of primary achalasia. Achalasic patients have smaller gallbladders than do others. It could be speculated that it is congenital and/or achalasic patients' gallbladder has incomplete relaxation (as in the lower esophageal sphincter of the achalasia).

Achalasia: a vagal disease

BACKGROUND

Achalasia is considered to be a primary motor disorder of the oesophagus. However, there is increasing evidence to suggest extra-oesophageal involvement in this disease. Vagal disturbances at different levels and extra-oesophageal dysmotility have been reported in several studies. The aim of this study was to examine cardiovascular reflexes in patients with achalasia further to evaluate the involvement of the autonomic nervous system outside the oesophagus in this entity.

METHODS

Five patients (age range 38-58 years, median 45 years) diagnosed with achalasia were assessed for the autonomic nerve function by the heart rate reaction to deep breathing (E/I ratio) and to tilt (acceleration and brake index). The blood pressure reaction to tilt was also assessed. The results were compared with a control group comprising 56 healthy individuals (age range 16-59 years, median 40 years).

RESULTS

Patients with achalasia had a significantly decreased E/I ratio compared with controls (absolute values 1.13 (0.23) (median value (interquartile range)) versus 1.38 (0.14): P=0.0309, age corrected values -1.39 (1.49) versus -0.25 (1.20): P=0.0457). This reflects impairment of the vagus nerve. In contrast, sympathetic nerves were not affected, as the acceleration index and brake index and postural blood pressure reaction were not disturbed in patients.

CONCLUSION

Patients with achalasia have autonomic nerve dysfunction in the vagal nerve outside the oesophagus.

Compounded Versus Proprietary Sincalide for Evaluation of Gallbladder Ejection Fraction

OBJECTIVE

To report a comparison of compounded and proprietary sincalide in the evaluation of gallbladder ejection fraction during hepatobiliary scintigraphy.

CASE SUMMARIES

Two patients were referred to nuclear medicine with symptoms consistent with hepatobiliary dysfunction. Both underwent hepatobiliary scintigraphy to evaluate anatomic and physiologic tract patency of the hepatobiliary system. Compounded sincalide, an adjuvant pharmaceutical used to evaluate gallbladder ejection fraction, was infused during hepatobiliary scintigraphy, and gallbladder ejection fractions were 11% and 24%, respectively. Hepatobiliary scintigraphy was repeated on both patients 72 hours later with proprietary sincalide used as the adjuvant pharmaceutical. The gallbladder ejection fractions were 32% and 72%, respectively.

DISCUSSION

The use of sincalide to evaluate gallbladder ejection fraction in hepatobiliary scintigraphy is widely accepted in the surgical and nuclear medicine community. In late 2001, the sole manufacturer of sincalide announced indefinite unavailability of the product. Following the announcement, several compounding pharmacies began selling extemporaneously compounded sincalide as a replacement. Use of the compounded product has assumed therapeutic equivalence.

CONCLUSION

Significant differences in gallbladder ejection fraction between compounded sincalide and sincalide in our patients are likely due to the intrinsic variability in response to sincalide. Clinicians should be aware of this variability, as well as the potential effect of concomitant medications.

Esophageal and gastric nitric oxide synthesizing innervation in primary achalasia

OBJECTIVE

We performed a qualitative and quantitative analysis of the nitrinergic neurons in the esophageal and gastric component of the lower esophageal sphincter (LES) and gastric fundus of patients with primary achalasia.

METHODS

Four muscle strips were obtained from the esophagogastric junction (two from the esophageal and two from the gastric side of the LES), and two from the gastric fundus of six patients with endstage achalasia who underwent an esophagogastric myotomy plus hemifundoplication. Control specimens were obtained from eight patients who underwent surgery for cancer of the thoracic esophagus. Fixed sections were processed for NADPH-diaphorase histochemistry and the number (mean +/- SE) of nitrinergic neurons per section was visually quantified in each specimen.

RESULTS

In the controls, nitric oxide fibers were distributed to the muscle layer and surrounding myenteric neurons of both the LES and the gastric fundus. By contrast, achalasic patients showed a marked decrease of nitric oxide nerves and labeled neurons in both esophageal and gastric components of the LES and the gastric fundus. Quantitative assessment in achalasic patients showed that the mean number of nitrinergic neurons was dramatically reduced in both the esophageal (0.2 +/- 0.1) and the gastric component (2 +/- 0.6) of the LES as compared to those in controls (15 +/- 5 and 12 +/- 4, respectively; p < 0.05); nitrinergic neurons in the gastric fundus (3 +/- 1) were significantly reduced in comparison to those of controls (10 +/- 2) (p < 0.05).

CONCLUSIONS

Our results indicate that achalasia is a motor disorder with an intrinsic inhibitory denervation of the esophageal and gastric component of the LES and of the proximal stomach, thus providing further evidence for an extraesophageal extension of the disease.

Gastrointestinal motor dysfunction, symptoms, and neuropathy in noninsulin-dependent (type 2) diabetes mellitus

Although relatively frequent. diabetic involvement of digestive tract motility has not been investigated extensively in different organs. The authors studied esophageal, gastric, and gallbladder motor function in 35 type 2 (noninsulin-dependent) diabetic patients to determine the extent of gut involvement. Of these patients, 27 (77%) had peripheral neuropathy, 12 (34%) had both peripheral and autonomic neuropathy, and 22 (63%) had gastrointestinal symptoms. Esophageal manometric abnormalities were recorded in 18 patients, and delayed radionuclide emptying of the esophagus was documented in 16 patients, with a 83% concordance between the two tests. Scintigraphic gastric emptying of solids was delayed in 56% of patients, whereas gallbladder emptying after cholecystokinin stimulation was reduced in 69% of them. In 74% of patients at least one of the viscera under investigation showed abnormal motor function; however, only 36% of patients displayed involvement of the three organs. Gastrointestinal symptoms, duration and therapy of diabetes, previous poor glycemic control, and retinopathy did not correlate with the presence or the extent of motor disorders. Neuropathy was not predictive of gastrointestinal involvement and its extent; however, when motor abnormalities were present in patients with neuropathy, these were usually more severe. Gastrointestinal motor disorders are frequent and widespread in type 2 diabetics, regardless of symptoms. Autonomic neuropathy has a poor predictive value on motor disorders (0.75 for the esophagus, 0.5 for the stomach, 0.8 for the gallbladder), thus suggesting the coexistence of other pathophysiologic mechanisms.

Dysmotility of the small intestine in achalasia

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.

Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia

We investigated the long-term efficacy and safety of intrasphincteric injections of botulinum toxin (100 U) in 57 patients with esophageal achalasia. One month after treatment, 50 patients had improved (88%); both symptom score and LES pressure were significantly reduced (P < 0.001). After a mean follow-up of 24+/-15 months (range 6-48), 43 patients (75%) are still in remission, although repeat injections of toxin were needed to achieve a stable effect on symptoms.

Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia

We investigated the long-term efficacy and safety of intrasphincteric injections of botulinum toxin (100 U) in 57 patients with esophageal achalasia. One month after treatment, 50 patients had improved (88%); both symptom score and LES pressure were significantly reduced (P < 0.001). After a mean follow-up of 24+/-15 months (range 6-48), 43 patients (75%) are still in remission, although repeat injections of toxin were needed to achieve a stable effect on symptoms.

Autonomic dysfunction in patients with achalasia of the oesophagus

It has been suggested that achalasia is associated with extraoesophageal sympathetic and parasympathetic dysfunction. In a prospective study we applied conventional ultrasonography and duplex sonography to investigate basal and postprandial peak systolic velocity (PSV), pulsatility index (PI) and resistance index (RI) of superior mesenteric artery and PSV of portal vein in nine patients with achalasia and 10 healthy controls (study I). In addition, in eight of these patients autonomic nervous function was investigated by pupillary function tests as well as cardiovascular reflex tests and compared with eight age- and sex-matched controls (study II). The results indicated that postprandial increase of PSV in the superior mesenteric artery was significantly lower, and postprandial decrease of PI and RI significantly higher in achalasia compared to healthy controls. In contrast, postprandial increase of PSV in the portal vein was not significantly different between both groups. Autonomic function tests revealed significant lower maximal pupillary contraction and redilatation velocities, significantly lower heart rate variation during orthostasis, deep respiration test and Valsalva manoeuvre in achalasia compared to controls. It is concluded that achalasia is associated with extraoesophageal autonomic nervous dysfunction that involves cardiovascular and pupillary function as well as regulation of mesenteric arterial blood flow.

Symptomatic gastroparesis in a patient with achalasia

We present a case of a patient with achalasia who developed symptomatic gastroparesis after botulinum toxin injection therapy. Symptoms responded to prokinetics. Pathophysiology of gastric motility disturbances in patients with achalasia is discussed.

Gastric myoelectrical and antroduodenal motor activity in patients with achalasia

Achalasia is a primary motor disorder of the oesophagus, in which the myenteric plexus is involved. However, abnormalities in other parts of the digestive tract have also been described in achalasia. Whether gastric myoelectrical and duodenal motor activity in these patients is also affected is unknown. Therefore, interdigestive and postprandial gastric myoelectrical and antroduodenal motor activity were studied in 11 patients with achalasia, using electrogastrography (EGG) and stationary antroduodenal manometry. Electrogastrographically, no differences were found in the gastric frequency, incidence of dysrhythmias and postprandial/fasting power ratio. In the interdigestive state a lower propagation velocity of phase III episodes was found in the achalasia patients, but other parameters were unaltered. Postprandially, no differences were found in the number of pressure waves, in the amplitude of pressure waves or in antroduodenal coordination. We conclude that gastric myoelectrical activity and antral motor activity in patients with achalasia is normal, suggesting an intact extrinsic and intrinsic neural innervation of the distal stomach. Although postprandial duodenal motility is normal, a lower propagation velocity of phase III suggests involvement of the small intestine in achalasia.

Cisapride and erythromycin prokinetic effects in gastroparesis due to type 1 (insulin-dependent) diabetes mellitus

BACKGROUND

Erythromycin, a macrolide antibiotic, has been shown to have gastric prokinetic effects and has been proposed as an alternative therapeutic option for diabetic gastroparesis. However, its efficacy has not yet been compared with that of other prokinetic drugs.

AIMS

The purpose of the present study was to compare the effects of erythromycin (250 mg 60 min before meals) and cisapride (10 mg 30 min before meals) on gastric emptying of healthy subjects and insulin-dependent diabetics.

PATIENTS AND METHODS

Six type 1 diabetic patients with a previous scintigraphic demonstration of gastroparesis and five healthy subjects were recruited for the study. Gastric emptying was scintigraphically studied by labelling the solid component of a standard test meal. Three scintigraphic studies, spaced at least 3 days apart, were carried out on each subject, basally and after erythromycin or cisapride.

RESULTS

Cisapride significantly accelerated gastric emptying in both the healthy subjects and the diabetic patients without any significant effect on the lag-time, whereas erythromycin in addition to a significant improvement of the overall gastric emptying also showed a pronounced effect on the lag-time in both groups (controls 25 +/- 5 vs. 37 +/- 8 min, P < or = 0.04; diabetics 65 +/- 11 vs. 112 +/- 16 min, P < 0.03).

CONCLUSIONS

Erythromycin may represent an effective therapeutic alternative to more established forms of treatment in patients with diabetic gastroparesis, especially when other drugs have failed.

Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Impaired gastric relaxation in patients with achalasia

Achalasia is considered a primary motility disorder confined to the oesophagus. The lower oesophageal sphincter (LOS) in achalasia is frequently hypertonic and manifests absent or incomplete relaxation in response to deglution. On the other hand, the LOS and the proximal stomach act physiologically as a functional unit whereby relaxation of the LOS during deglution is associated with receptive relaxation of the proximal stomach. Thus, this study investigated the hypothesis that impaired LOS relaxation in patients with achalasia might be associated with impaired relaxation of the proximal stomach. The study consisted of 20 patients with achalasia and 10 healthy controls. Gastric tone variations were quantified using an electronic barostat. Firstly, the study established the basal gastric tone (intragastric volume at the minimal distending pressure+1 mm Hg) and gastric compliance (volume/pressure relation) during isobaric distension (increasing stepwise the intragastric pressure from 0 to 20 mm Hg up to 600 ml). Secondly, the gastric tone response to cold stress (hand immersion into ice water for five minutes) or to control stimuli (water at 37 degrees) was determined. Basal gastric tone mean (SEM) was similar in achalasia and in healthy controls (125 (9) ml v 138 (9) ml, respectively). Compliance was linear and similar in both groups, which also showed similar gastric extension ratios (58 (7) ml/mm Hg v 57 (6) ml/mm Hg). Cold stress induced a gastric relaxatory response that, as a group, was significantly lower in achalasia than in healthy controls (volume: 43 (20) ml v 141 (42) ml; p < 0.05). The responses in each group were not uniform, five of the 20 patients with achalasia showed definite (volume > 100 ml) relaxatory responses whereas four of the 10 healthy controls did not. In conclusion, reflex gastric relaxation is impaired in most patients with achalasia showing that the proximal stomach, and not exclusively the oesophagus, may be effected by the disease.

Autonomic dysfunction in patients with achalasia

It has been previously shown that patients with achalasia may have motor abnormalities of the stomach, small bowel and biliary system. This study investigates whether a disturbance of extraintestinal autonomic function occurs. Autonomic function studies were performed in 15 patients with achalasia and 15 age- and sex-matched healthy controls. Pupillograms were obtained during darkness, light exposure and after pilocarpine administration. Cardiovascular function studies included determinations of heart rate variation during deep breathing and orthostasis. In addition, we determined blood pressure changes in response to sustained handgrip, cold exposure and orthostasis. Neurohormonal function was investigated by measuring serum pancreatic polypeptide (PP) levels prior to and following sham feeding. Pupillary function did not differ in patients as compared with controls. However, 9 of 15 patients (95% CI: 32-84%) and none of the controls showed at least one abnormal autonomic cardiovascular response. A significant difference between the two groups was observed in sympathetic function (P = 0.023). More patients than controls did not respond to sham feeding with a PP increase. It is concluded that some patients with achalasia exhibit an abnormality of the autonomic nervous system that extends beyond the gastrointestinal tract. These abnormalities mainly concern cardiovascular function but may also involve neurohormonal responses.

Gastric emptying of solid meals in achalasic patients after successful pneumatic dilatation of the cardia

Gastric emptying of a solid meal was measured by ultrasound scanning in 16 achalasic patients following successful pneumatic dilatation of the lower esophageal sphincter. The data were compared with those of a control group of 15 healthy subjects. Fasting and maximal postcibal antral sections were very similar in the two groups. On the contrary, the time interval before maximal antral dilatation, and the time necessary for the emptying of half or of the whole meal were significantly longer in the achalasic patients than in the controls. Half of the achalasic patients had longer emptying times than the upper normal limit. The percentage of the meal retained in the antrum at each hourly interval was significantly higher in the achalasic group. The finding of a high prevalence of gastric emptying disturbances suggests that the functional derangement in achalasia is not limited to the esophagus.

Patients with achalasia lack nitric oxide synthase in the gastro-oesophageal junction

The abnormal function of the lower oesophageal sphincter in achalasia is likely to be due to impaired nonadrenergic, noncholinergic (NANC) inhibitory input. Since recent studies in animals suggest that nitric oxide (NO) is implicated physiologically in the inhibitory responses of the lower oesophageal sphincter, we have investigated whether the synthesis of NO is altered in the gastro-oesophageal junction of patients with achalasia. NO synthase activity was investigated in samples of tissue from the gastro-oesophageal junction obtained during surgery in eight patients with typical achalasia and six non-achalasic controls who underwent oesophagectomy for reasons other than sphincter dysfunction. The NO synthase activity was determined by the transformation of 14C-L-arginine into 14C-L-citrulline in tissue homogenates. In addition, immunohistochemical staining of the tissues was performed using a polyclonal antibody raised against a peptide sequence of rat brain NO synthase. Furthermore, the relaxant response to an exogenous NO donor (sodium nitroprusside, SNP) was measured in vitro in muscle strips obtained from two patients with achalasia and in two non-achalasic controls. NO synthase activity was detected in each of the samples obtained from six control patients (0.59 +/- 0.21 pmol mg-1 min-1; mean +/- SE). By contrast, none of the samples obtained from the eight patients with achalasia had any detectable NO synthase activity. Immunohistochemical studies confirmed the presence of NO synthase in the myenteric plexus of the gastro-oesophageal junction of control patients and its absence in achalasia. SNP relaxed muscle strips precontracted with bethanechol in both control samples and those from patients with achalasia.(ABSTRACT TRUNCATED AT 250 WORDS)