Return of esophageal peristalsis in achalasia secondary to gastric cancer

Pseudoachalasia: a diagnostic challenge. When to consider and how to manage?

Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.

Achalasia Secondary to Submucosal Invasion by Poorly Differentiated Adenocarcinoma of the Cardia, Siewert II: Consideration on Preoperative Workup

Secondary achalasia due to submucosal invasion of cardia by gastric cancer is a rare condition. We report a case of pseudoachalasia, secondary to the involvement of gastroesophageal junction by poorly differentiated gastric cancer, initially mistaken as idiopathic form. We focus on the difficulty to establish differential diagnosis only on the basis of routine exams and we stress the necessity of "second level" instrumental exams; EUS in routine workup in selected patients should be considered. We support that routine workup based on history, clinical presentation, radiological and endoscopic findings, and certainly manometry could be insufficient for a correct differential diagnosis between primary and secondary forms in some patients.

Pseudoachalasia: A peculiar case report and review of the literature

Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.

Palliation with oesophageal metal stent of pseudoachalasia from gastric carcinoma at the cardia: a case report

We present an 82-year-old woman with a 3-month history of progressive dysphagia and a normal initial upper gastrointestinal endoscopy. The diagnosis of pseudoachalasia was suspected by oesophageal manometric and barium swallow studies, and confirmed by biopsies revealing an intestinal type carcinoma of the stomach at a repeated endoscopy. In view of the history of heart disease, diabetes, and old age, this patient was treated by a partially covered Ultraflex self-expanding metal stent (Boston Scientific, Natick, MA, USA) placed into the oesophageal body with no direct complications and obtaining the relief from dysphagia. During the 11-month follow-up she was treated for an iron deficiency anaemia due to reflux oesophagitis with ulcerations in the oesophageal body and died from myocardial infarction. According to the localization of the cancer, the old age, and the presence of comorbidities, we should recommend the insertion of a partially covered self-expanding metal stent as a reasonable palliative treatment in selected subjects with pseudoachalasia.

Pseudoachalasia: a case series and analysis of the literature

OBJECTIVE

Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus.

MATERIAL AND METHODS

Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect.

RESULTS

In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologic examination of the esophagus proved to be of little value in distinguishing between the diseases. In the majority of cases only surgical exploration revealed the underlying cause. A coincidence of primary achalasia and disorders of the gastroesophageal junction was excluded by showing return of peristalsis following treatment. The analysis of the literature showed a total of 264 cases of pseudoachalasia in 122 publications. Most cases of were due to malignant disease (53.9% primary and 14.9% secondary malignancy), followed by benign lesions (12.6%) and sequelae of surgical procedures at the distal esophagus or proximal stomach (11.9%). In rare instances, the disease was an expression of a paraneoplastic process due to distant neuronal involvement rather than to local invasion with destruction of the myenteric plexus (2.6%).

CONCLUSIONS

The diagnosis of pseudoachalasia is difficult to establish by conventional diagnostic measures. The main distinguishing feature of secondary versus primary achalasia is the complete reversal of pathologic motor phenomena following successful therapy of the underlying disorder.

Association of pseudoachalasia with advancing cancer of the gastric cardia

BACKGROUND

Pseudoachalasia is attributable to malignant tumors of the gastric cardia in more than 50% of cases. Study of the progression of esophageal manometric abnormalities with increasing tumorous involvement of the esophagogastric junction may improve our understanding of the pathophysiologic characteristics of pseudoachalasia.

METHODS

During a 2-year period, esophageal manometric characteristics were evaluated for 17 of 21 consecutive patients with cancer of the gastric cardia. Manometry was not possible in the other four. Manometric parameters assessed included lower esophageal sphincter pressure, percentage lower esophageal sphincter relaxation, and percentage failed peristalsis. The extent of malignant involvement of the esophagogastric junction was graded as none, less than 50% of the circumference, or 50% or more of the circumference, assessed from surgical specimens in 13 cases and endoscopy in 4 cases.

RESULTS

Pseudoachalasia was diagnosed in 3 cases, all with 50% or greater circumferential involvement of the esophagogastric junction. The first manometric indication of evolving pseudoachalasia was impaired lower esophageal sphincter relaxation; loss of peristaltic function was a secondary consequence.

CONCLUSIONS

These findings suggest that the primary mechanism of pseudoachalasia with gastric cardia cancer is malignant stenosis of the esophagogastric junction.

Clinical presentation and evaluation of malignant pseudoachalasia

Malignant pseudoachalasia can be indistinguishable from primary achalasia on routine clinical evaluation, often resulting in a delay in diagnosis. To better define the clinical features and appropriate management of this disease, the course of five patients discovered to have pseudoachalasia after being referred for a minimally invasive Heller myotomy was reviewed, as were 67 cases of pseudoachalasia previously reported in the literature. Patients with an occult malignancy tended to present with shorter durations of symptoms, greater weight loss, and at a more advanced age than patients with primary achalasia. Since contrast radiography and endoscopy frequently failed to differentiate these two diseases, persons with presumed achalasia meeting these criteria who are referred for minimally invasive surgery should undergo additional imaging to rule out an occult malignancy, since this condition cannot be reliably detected during the course of a thoracoscopic or laparoscopic esophagomyotomy.

Are the motility abnormalities of achalasia reversible? An experimental outflow obstruction in the feline model

BACKGROUND

Experimental and clinical evidence suggests that the loss of esophageal body function in achalasia may be a result of the outflow obstruction of a nonrelaxing, hypertensive lower esophageal sphincter. The reversibility of such abnormalities has implications to the timing of therapeutic interventions. This study was designed to evaluate the evolution and reversibility of motility abnormalities resulting from esophageal outflow obstruction in cats.

METHODS

Twenty adult cats were divided into 2 groups. Group 1 consisted of 4 cats that underwent laparotomy as a sham procedure. Group 2 consisted of 16 cats that underwent surgical placement of a loose Gore-tex expanded polytetrafluoroethylene (W. L. Gore, Elkton, Md) band calibrated to 110% of the circumference of the gastroesophageal junction. The band was removed from 4 randomly selected cats each at 1, 2, 4, and 6 weeks after placement. Esophageal manometry was performed before placement of the band, at weekly intervals after placement of the band, and after removal of the band. The resting pressure and percent relaxation of the lower esophageal sphincter (LES), in addition to amplitude, duration, and propagation of esophageal body contractions, were measured at each interval. Data are expressed as median and interquartile range and compared with use of the Mann-Whitney U test for independent samples.

RESULTS

The LES resting pressure remained unchanged after placement of the band, but sphincter compliance was reduced, as manifested by a significant reduction in the percent of sphincter relaxation (98% prebanding, 65% postbanding, P < .05). The median amplitude of esophageal contraction decreased significantly after banding. By 6 weeks after banding the esophagus was markedly dilated and exhibited aperistaltic, low-amplitude esophageal motility typical of that seen in clinical achalasia. Importantly, removal of the bands resulted in a prompt return of both peristalsis and amplitude of contraction.

CONCLUSIONS

Loss of compliance of the lower esophageal sphincter produces outflow obstruction with the resultant loss of esophageal contraction amplitude and peristaltic waveform typical of achalasia in humans. These abnormalities were reversible after relief of obstruction in the feline model and may indicate that early relief of outflow obstruction in clinical achalasia may preserve esophageal function in patients.

Achalasia due to diffuse esophageal leiomyomatosis and inherited as an autosomal dominant disorder. Report of a family study

Although achalasia is usually of idiopathic origin, it may be secondary to another disease process such as neoplasia. The first description of a familial achalasia syndrome that appears to be secondary to diffuse esophageal leiomyomatosis with entrapment of nerve ganglia is presented. Documented in four generations of a family, the disease followed an autosomal dominant mode of inheritance. Long lower esophageal sphincter pressure zones and a high incidence of epiphrenic diverticula were interesting accompaniments of achalasia in this family. Many achalasia-affected family members have also had associated intestinal leiomyomas or neurofibromas. Affected family members also had urticaria pigmentosa, and some had systemic mast cell disease as well.

Esophageal achalasia secondary to mesothelioma

Achalasia secondary to malignancy is rare, with most cases associated with gastric adenocarcinoma of the gastroesophageal junction. This report describes the clinicopathologic features of a 64-year-old man found to have mesothelioma as the cause of secondary achalasia. To our knowledge, this is the first case of secondary achalasia produced by a mesothelioma. We reviewed the English literature in regard to achalasia induced by tumors.

Severe destruction of esophageal nerves in a patient with achalasia secondary to gastric cancer. A possible role of eosinophil neurotoxic proteins

We present a case of secondary achalasia due to an adenocarcinoma of the stomach with no tumor infiltration of the esophagus. Immunohistochemical staining revealed a massive infiltration of activated eosinophils in the muscularis of the esophagus with secretion of the highly cytotoxic and neurotoxic eosinophil cationic protein (ECP). Immunohistochemical staining for the neuropeptides VIP and substance P, as well as the histochemical demonstration of AChE, revealed a nearly total absence of all three neurotransmitters/modulators compared to control. The hypothesis is advanced that eosinophil neurotoxicity is the cause of secondary achalasia.

Pancreatic pseudocyst as a cause for secondary achalasia

Secondary achalasia is commonly due to cancer. Benign causes are rare and an association with pancreatitis has never been made. Our patient presented with clinical, manometric, endoscopic, and radiographic features of achalasia that occurred in conjunction with a pancreatic pseudocyst extending into the mediastinum. Documentation of this unique relationship was made on two occasions after episodes of complicated pancreatitis and was confirmed by restoration of normal esophageal function after drainage of the pseudocyst. Onset of dysphagia occurring in association with pancreatitis suggests the presence of a pseudocyst and secondary achalasia.

Family occurrence of achalasia and diffuse spasm of the oesophagus

In view of the unknown aetiology of achalasia and diffuse oesophageal spasm we report four families (father/son, mother/son, brother/brother, cousin/cousin) with achalasia and oesophageal spasm examined by radiology, endoscopy and manometry. Family occurrence of oesophageal motor disorders supports the hypothesis that a genetic trait may play a role in the pathogenesis. The family coincidence of achalasia and oesophageal spasm supports a close relationship between the two diseases.

Esophageal achalasia syndromes

Esophageal achalasia, characterized by failure of the lower esophageal sphincter to relax normally with swallowing and esophageal aperistalsis, may be primary or secondary to another disorder (in the United States most often cancer). Primary achalasia is of unclear etiology but almost certainly is a disorder of the innervation of the smooth muscle portion of the esophagus. This article reviews the classification and clinical features of achalasia syndromes, as well as current concepts of pathogenesis, diagnosis, complications, and therapy of this group of disorders.

Comparison of pseudoachalasia and achalasia

Malignancies involving the gastric cardia or distal esophagus can result in a clinical syndrome termed pseudoachalasisa that mimics idiopathic achalasia. If not promptly recognized, pseudoachalasia can result in inappropriate pneumatic dilatation of the lower esophageal sphincter segment and delay appropriate treatment of the underlying malignancy. During the past 14 years, six patients with pseudoachalasia and 161 patients with primary idiopathic achalasia were encountered. Pseudoachalasia occurred mainly in the elderly and represented about 9 percent of these patients over 60 years of age with suspected achalasia. Five of the six pseudoachalasia cases were secondary to adenocarcinoma that originated in the gastric fundus, and one was caused by a squamous cell carcinoma of the distal esophagus. Conventional esophageal manometry did not discriminate achalasia from pseudoachalasia. On the other hand, esophagogastroscopy with biopsy resulted in a diagnosis of pseudoachalasia in five of these cases and in 24 of 32 cases reported previously. Ominous endoscopic findings are mucosal ulceration or nodularity, reduced compliance of the esophagogastric junction, or an inability to pass the endoscope into the stomach. Radiographic evaluation, particularly in conjunction with amyl nitrite inhalation, was also useful in discriminating pseudoachalasia from primary achalasia. It is concluded that pseudoachalasia generally mimics idiopathic achalasia imperfectly and can usually be diagnosed prior to surgery by fastidious endoscopic and radiographic examination.

Achalasia secondary to nongastrointestinal malignancies

Secondary or "pseudo" achalasia of the esophagus can mimic idiopathic achalasia radiographically and can be difficult to diagnose. Typically, it is due to invasive carcinoma involving the gastroesophageal junction, usually gastric adenocarcinoma. Occasionally, an achalasialike condition can be produced by tumors not involving the gastroesophageal junction. We report 2 cases, 1 of lung carcinoma and the other of hepatoma, in which the patients had radiographic and endoscopic changes compatible with achalasia. However, the onset of symptoms was abrupt and the patients were elderly; these are unusual features for primary achalasia. There have been several other reports of nongastrointestinal neoplasms producing a clinical and radiographic picture similar to achalasia. Although there are several theories as to the cause, our cases would support the concept that direct tumor involvement of the gastroesophageal junction is not necessary to produce significant esophageal dysmotility.