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Kim Y, Shibli F, Fu Y, Song G, Fass R. Multiple Sclerosis Is Associated With Achalasia and Diffuse Esophageal Spasm. J Neurogastroenterol Motil 2023; 29:478-485. [PMID: 37528077 PMCID: PMC10577467 DOI: 10.5056/jnm22173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 08/03/2023] Open
Abstract
Background/Aims Multiple sclerosis (MS) is an inflammatory disease characterized by the demyelination of primarily the central nervous system. Diffuse esophageal spasm (DES) and achalasia are both disorders of esophageal peristalsis which cause clinical symptoms of dysphagia. Mechanisms involving dysfunction of the pre- and post-ganglionic nerve fibers of the myenteric plexus have been proposed. We sought to determine whether MS confers an increased risk of developing achalasia or DES. Methods Cohort analysis was done using the Explorys database. Univariate logistic regression was performed to determine the odds MS confers to each motility disorder studied. Comparison of proportions of dysautonomia comorbidities was performed among the cohorts. Patients with a prior diagnosis of diabetes mellitus, chronic Chagas' disease, opioid use, or CREST syndrome were excluded from the study. Results Odds of MS patients developing achalasia or DES were (OR, 2.09; 95% CI, 1.73-2.52; P < 0.001) and (OR, 3.15; 95% CI, 2.89-3.42; P < 0.001), respectively. In the MS/achalasia cohort, 27.27%, 18.18%, 9.09%, and 45.45% patients had urinary incontinence, gastroparesis, impotence, and insomnia, respectively. In the MS/DES cohort, 35.19%, 11.11%, 3.70%, and 55.56% had these symptoms. In MS patients without motility disorders, 12.64%, 0.79%, 2.21%, and 21.85% had these symptoms. Conclusions Patients with MS have higher odds of developing achalasia or DES compared to patients without MS. MS patients with achalasia or DES have higher rates of dysautonomia comorbidities. This suggests that these patients have a more severe disease phenotype in regards to the extent of neuronal degradation and demyelination causing the autonomic dysfunction.
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Affiliation(s)
- Yeseong Kim
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Fahmi Shibli
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Yuhan Fu
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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2
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Roman S, Hebbard G, Jung KW, Katz P, Tutuian R, Wong R, Wu J, Yadlapati R, Sifrim D. Chicago Classification Update (v4.0): Technical review on diagnostic criteria for distal esophageal spasm. Neurogastroenterol Motil 2021; 33:e14119. [PMID: 33666299 DOI: 10.1111/nmo.14119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 01/18/2023]
Abstract
Distal esophageal spasm (DES) is defined as a manometric pattern of at least 20% of premature contractions in a context of normal esophago-gastric junction relaxation in a patient with dysphagia or non-cardiac chest pain. The definition of premature contraction requires the measurement of the distal latency and identification of the contractile deceleration point (CDP). The CDP can be difficult to localize, and alternative methods are proposed. Further, it is important to differentiate contractile activity and intrabolus pressure. Multiple rapid swallows are a useful adjunctive test to perform during high-resolution manometry to search for a lack of inhibition that is encountered in DES. The clinical relevance of the DES-manometric pattern was raised as it can be secondary to treatment with opioids or observed in patients referred for esophageal manometry before antireflux surgery in absence of dysphagia and non-cardiac chest pain. Further idiopathic DES is rare, and one can argue that when encountered, it could be part of type III achalasia spectrum. Medical treatment of DES can be challenging. Recently, endoscopic treatments with botulinum toxin and peroral endoscopic myotomy have been evaluated, with conflicting results while rigorously controlled studies are lacking. Future research is required to determine the role of contractile vigor and lower esophageal sphincter hypercontractility in the occurrence of symptoms in patients with DES. The role of impedance-combined high-resolution manometry also needs to be evaluated.
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Affiliation(s)
- Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon and Lyon I University, Lyon, France
| | - Geoff Hebbard
- Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Phil Katz
- Weill Cornell Medicine, New York, NY, USA
| | - Radu Tutuian
- Clinic for Gastroenterology and Hepatology, Bürgerspital Solothurn, Solothurn, Switzerland.,University of Berne, Berne, Switzerland
| | - Reuben Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore, Singapore
| | - Justin Wu
- The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Rena Yadlapati
- Division of Gastroenterology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
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3
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Trudgill NJ, Sifrim D, Sweis R, Fullard M, Basu K, McCord M, Booth M, Hayman J, Boeckxstaens G, Johnston BT, Ager N, De Caestecker J. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut 2019; 68:1731-1750. [PMID: 31366456 PMCID: PMC6839728 DOI: 10.1136/gutjnl-2018-318115] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Abstract
These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.
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Affiliation(s)
- Nigel J Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bomwich, UK
| | - Daniel Sifrim
- Centre of Gastroenterology Research, Queen Mary University London, London, UK
| | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Fullard
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
| | - Kumar Basu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - John Hayman
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Guy Boeckxstaens
- Gastroenterology, University Hospital, KU Leuven, Leuven, Belgium
| | - Brian T Johnston
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, UK
| | - Nicola Ager
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
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4
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Vercoe H, Mulla M, Lewis WG, Foliaki A, Chan DSY. Systematic review and meta-analysis on the treatment of diffuse esophageal spasm. Eur Surg 2019. [DOI: 10.1007/s10353-019-0574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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5
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Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med 2018; 131:1034-1040. [PMID: 29605413 DOI: 10.1016/j.amjmed.2018.02.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 12/28/2022]
Abstract
Distal esophageal spasm is a rare motility disorder presenting principally with nonobstructive dysphagia and noncardiac chest pain. In symptomatic patients, the manometric diagnosis is made when >10% of the wet swallows have simultaneous and/or premature contractions intermixed with normal peristalsis. We characterize manometry and barium as complementary diagnostic approaches, and given the intermittent nature of the disorder, one should be always aware that it is almost impossible to rule out spasm. Treatment is difficult; we propose an approach beginning with the least invasive intervention.
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Affiliation(s)
- Mohamed Khalaf
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston.
| | | | - Puja Sukhwani Elias
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
| | - Donald Castell
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
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6
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Ponds FAM, Smout AJPM, Fockens P, Bredenoord AJ. Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm. Scand J Gastroenterol 2018; 53:252-255. [PMID: 29338493 DOI: 10.1080/00365521.2018.1424933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Treatment options are limited and often poorly effective. Peroral endoscopic myotomy (POEM) seems an effective and attractive new treatment option for DES. In this case report we describe some of the difficulties that could arise. MATERIALS AND METHODS A 84-year old man with therapy-refractory DES and complaints of severe dysphagia and chest pain underwent a POEM procedure under general anesthesia. A longer myotomy was performed to cleave the circular muscle layer from start till end of the spastic contractions. RESULTS The length of the myotomy was 16 cm. Hyperactive spastic contractions during the procedure complicated the creation of the submucosal tunnel, extended the duration (134 vs. 60-90 min for achalasia), increased postoperative pain and prolonged hospital admission. Intravenously nitroglycerin peroperative diminished spastic contractions. Postoperative a remnant of spastic contractions was present, proximal to the myotomy, causing persistent symptoms. CONCLUSION Performing POEM for DES is challenging due to reactive hyperactive spastic contractions during the procedure causing technical difficulties and an extended procedure. A long myotomy, several centimeters above the proximal border of the spastic region, is essential to prevent remnants of spasticity.
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Affiliation(s)
- Fraukje Anna-Marie Ponds
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - André J P M Smout
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Paul Fockens
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Albert J Bredenoord
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
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7
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Miranda García P, Casals Seoane F, Gonzalez JM, Barthet M, Santander Vaquero C. Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:719-726. [PMID: 28724307 DOI: 10.17235/reed.2017.4732/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND/AIMS Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. METHODS We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. RESULTS Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. CONCLUSIONS POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.
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9
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Quintavalla F, Menozzi A, Pozzoli C, Poli E, Donati P, Wyler DK, Serventi P, Bertini S. Sildenafil improves clinical signs and radiographic features in dogs with congenital idiopathic megaoesophagus: a randomised controlled trial. Vet Rec 2017; 180:404. [PMID: 28188161 DOI: 10.1136/vr.103832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2017] [Indexed: 11/04/2022]
Abstract
We evaluated the efficacy of oral sildenafil citrate in dogs with congenital idiopathic megaoesophagus (CIM). Twenty-one puppies were randomly assigned to two groups (treatment and control). The dogs were given sildenafil oral suspension 1 mg/kg every 12 hours for 14 days or placebo in a masked fashion. Clinical signs (frequency of regurgitation and weight gain) and oesophagrams (relative oesophageal diameter, ROD) were evaluated in order to assess the efficacy of drug treatment, by examiners who were unaware of the study protocol. In addition, a set of in vitro experiments on isolated samples of canine lower oesophageal sphincter (LOS) was performed, and the effects of increasing concentrations of sildenafil on basal tone and electrically-stimulated motility were assessed. Sildenafil administration significantly reduced the number of regurgitation episodes (0.88±1.40 v 2.65±1.56, P<0.0001) and significantly increased weight gain in the treated dogs compared to controls (79.76±28.30 per cent v 53.40±19.30 per cent, P=0.034). ROD values, at the end of the treatment period, were significantly decreased in the sildenafil group, compared to pre-treatment values (0.97±0.19 v 0.24±0.14, P<0.0001), in contrast to control subjects (0.98±0.17 v 1.10±0.25, P=0.480). In accordance with the in vivo findings, sildenafil dose-dependently reduced basal tone and increased electrically-induced relaxation of dog LOS samples. These results suggest that sildenafil citrate helps ameliorate clinical and radiographic signs in dogs with CIM by reducing LOS tone, and could represent a novel therapeutic tool for the treatment of this disease.
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Affiliation(s)
- F Quintavalla
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - A Menozzi
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - C Pozzoli
- Department of Neuroscience, University of Parma, Parma, Italy
| | - E Poli
- Department of Neuroscience, University of Parma, Parma, Italy
| | | | - D K Wyler
- The Animal Medical Hospital and Whitestone Veterinary Care, New York, NY, USA
| | - P Serventi
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - S Bertini
- Department of Veterinary Science, University of Parma, Parma, Italy
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10
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Esophagus: Radiologic Evaluation of Esophageal Function. Dysphagia 2017. [DOI: 10.1007/174_2017_135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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Pharmacologic Treatment of Esophageal Dysmotility. Dysphagia 2017. [DOI: 10.1007/174_2017_127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Crespin OM, Tatum RP, Yates RB, Sahin M, Coskun K, Martin AV, Wright A, Oelschlager BK, Pellegrini CA. Esophageal hypermotility: cause or effect? Dis Esophagus 2016; 29:497-502. [PMID: 25893778 DOI: 10.1111/dote.12367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.
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Affiliation(s)
- O M Crespin
- University of Washington, Surgery, Seattle, WA, USA
| | - R P Tatum
- University of Washington, Surgery, Seattle, WA, USA
| | - R B Yates
- University of Washington, Surgery, Seattle, WA, USA
| | - M Sahin
- University of Washington, Surgery, Seattle, WA, USA
| | - K Coskun
- University of Washington, Surgery, Seattle, WA, USA
| | - A V Martin
- University of Washington, Surgery, Seattle, WA, USA
| | - A Wright
- University of Washington, Surgery, Seattle, WA, USA
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13
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De Schepper HU, Ponds FAM, Oors JM, Smout AJPM, Bredenoord AJ. Distal esophageal spasm and the Chicago classification: is timing everything? Neurogastroenterol Motil 2016; 28:260-5. [PMID: 26553751 DOI: 10.1111/nmo.12721] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 10/06/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as premature esophageal contractions (distal latency [DL] <4.5 s) for ≥20% of swallows, in the presence of a normal mean integral relaxation pressure (IRP). However, some patients with symptoms of DES have rapid contractions with a normal DL. The aim of this study was to characterize these patients and compare their clinical characteristics to those of patients classified as DES. METHODS We retrospectively compared clinical characteristics and high-resolution manometry findings of patients with rapid contractions with normal latency to those meeting the Chicago classification criteria for DES. KEY RESULTS Over a 3-year period, nine patients were diagnosed with DES and 14 showed rapid contractions in the distal esophagus with normal latency. The latter were younger than DES patients (60 ± 4 vs 72 ± 3 years, p < 0.05). Dysphagia and retrosternal pain occurred to a similar degree in both groups. Weight loss and abnormal barium esophagogram tended to be more frequent in DES patients. There was no difference in contractile front velocity (CFV) and in distal contractile integral (DCI) between patients with DES and rapid contractions with normal latency. Lower esophageal sphincter pressures were not different between groups. However, IRP was significantly higher in DES compared to rapid contractions with normal latency (11.7 ± 0.6 mmHg vs 7.6 ± 1.2 mmHg, p < 0.05), albeit still within the normal range. CONCLUSIONS & INFERENCES These data suggest that patients with simultaneous contractions with normal latency represent a group of patients with many features similar to DES.
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Affiliation(s)
- H U De Schepper
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
| | - F A M Ponds
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - J M Oors
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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14
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Abstract
PURPOSE OF REVIEW Distal esophageal spasm (DES) is a rare esophageal motility disorder associated with dysphagia and chest pain. In 2011, the diagnosis of DES was refined based on the occurrence of premature (rather than rapid) contractions by high-resolution manometry. New therapeutic options have also been recently proposed. Thus, a review on DES incorporating publications since 2012 is timely because of these revisions in definition and management. RECENT FINDINGS DES remains a heterogeneous clinical disorder. Its pathophysiology is still debated and DES might be related to achalasia. Alternatively, it might be secondary to medications, especially opiates. Endoscopic ultrasound might be informative diagnostically by demonstrating muscularis propria hypertrophy and thickening. Botulinum toxin injection in the esophageal body has been shown superior to placebo to relieve symptoms associated with DES. Finally, per oral endoscopic myotomy is a promising therapeutic approach, but may be less effective in DES than in achalasia. SUMMARY The diagnosis of DES should lead to a systematic search for medication that might promote the occurrence of esophageal dysmotility. Endoscopic treatment of DES (botulinum toxin injection or per oral endoscopic myotomy) should be further evaluated in controlled studies using current diagnostic criteria by high-resolution manometry.
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15
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Roman S, Pioche M, Mion F. Per oral endoscopic myotomy (POEM) for all spastic esophageal disorders? Endosc Int Open 2015; 3:E202-4. [PMID: 26171431 PMCID: PMC4486033 DOI: 10.1055/s-0034-1391417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 12/28/2014] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Lyon, France ,LabTau, INSERM, U1032, Lyon, France ,Corresponding author Sabine Roman, MD Digestive PhysiologyHôpital Edouard Herriot5, Place d’Arsonval69437 Lyon Cédex 03France+33-4-72-11-01-47
| | - Mathieu Pioche
- LabTau, INSERM, U1032, Lyon, France ,Gastroenterology, Hospices Civils de Lyon and Lyon I University, Lyon, France
| | - François Mion
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Lyon, France ,LabTau, INSERM, U1032, Lyon, France
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16
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Lipe DN, Borden N. Rare radiological pattern of diffuse esophageal spasm. West J Emerg Med 2015; 16:426-7. [PMID: 25987921 PMCID: PMC4427218 DOI: 10.5811/westjem.2015.3.25826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/06/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Demis N Lipe
- Martin Army Community Hospital, Department of Emergency Medicine, Fort Benning, Georgia
| | - Nathan Borden
- Carl R. Darnall Army Medical Center, Department of Emergency Medicine, Fort Hood, Texas
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17
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Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment. Curr Gastroenterol Rep 2015; 16:421. [PMID: 25376746 DOI: 10.1007/s11894-014-0421-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.
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Marjoux S, Brochard C, Roman S, Gincul R, Pagenault M, Ponchon T, Ropert A, Mion F. Botulinum toxin injection for hypercontractile or spastic esophageal motility disorders: may high-resolution manometry help to select cases? Dis Esophagus 2014; 28:735-41. [PMID: 25212219 DOI: 10.1111/dote.12282] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic injections of botulinum toxin in the cardia or distal esophagus have been advocated to treat achalasia and spastic esophageal motility disorders. We conducted a retrospective study to evaluate whether manometric diagnosis using the Chicago classification in high-resolution manometry (HRM) would be predictive of the clinical response. Charts of patients with spastic and hypertensive motility disorders diagnosed with HRM and treated with botulinum toxin were retrospectively reviewed at two centers. HRM recordings were systematically reanalyzed, and a patient's phone survey was conducted. Forty-five patients treated between 2008 and 2013 were included. Most patients had achalasia type 3 (22 cases). Other diagnoses were jackhammer esophagus (8 cases), distal esophageal spasm (7 cases), esophagogastric junction outflow obstruction (5 cases), nutcracker esophagus (1 case), and 2 unclassified cases. Botulinum toxin injections were performed into the cardia only in 9 cases, into the wall of the distal esophagus in 19 cases, and in both locations (cardia and distal esophagus) in 17 cases. No complication occurred in 31 cases. Chest pain was noticed for less than 7 days in 13 cases. One death related to mediastinitis occurred 3 weeks after botulinum toxin injection. Efficacy was assessed in 42 patients: 71% were significantly improved 2 months after botulinum toxin, and 57% remained satisfied for more than 6 months. No clear difference was observed in terms of response according to manometric diagnosis; however, type 3 achalasia previously dilated and with normal integrated relaxation pressure (4s-integrated relaxation pressure < 15 mmHg) had the worst outcome: none of these patients responded to the endoscopic injection of botulinum toxin. Endoscopic injections of botulinum toxin may be effective in some patients with spastic or hypercontractile esophageal motility disorders. The manometric Chicago classification diagnosis does not seem to predict the results. Prospective randomized trials are required to identify patients most likely to benefit from esophageal botulinum toxin treatment.
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Affiliation(s)
- S Marjoux
- Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France
| | - C Brochard
- Department of Digestive Diseases, CHU Rennes, Rennes, France
| | - S Roman
- Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.,Department of Physiology, Lyon 1 University, Lyon, France.,Inserm U1032, LabTAU, Lyon, France
| | - R Gincul
- Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France
| | - M Pagenault
- Department of Digestive Diseases, CHU Rennes, Rennes, France
| | - T Ponchon
- Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.,Department of Physiology, Lyon 1 University, Lyon, France.,Inserm U1032, LabTAU, Lyon, France
| | - A Ropert
- Department of Digestive Diseases, CHU Rennes, Rennes, France
| | - F Mion
- Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.,Department of Physiology, Lyon 1 University, Lyon, France.,Inserm U1032, LabTAU, Lyon, France
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Review of current diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter. Curr Opin Otolaryngol Head Neck Surg 2014; 21:543-7. [PMID: 24157634 DOI: 10.1097/moo.0000000000000002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW To cover the diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter. An outline of the presentation and manometric features of these conditions will precede a discussion of therapies. All of these diagnoses are made manometrically, even though they may be suspected by presentation and by findings at video fluoroscopic swallow or gastroscopy testing. RECENT FINDINGS The advent of high-resolution manometry testing has allowed a better understanding of these motility disorders, and the ability to standardize the diagnoses by the use of the Chicago Classification is a major step forward. Recent developments show that botulinum toxin and perioral myotomy can be an effective treatment for some patients. This should bring more therapies to the fore in the future, but at present there is still the need for more prospective study of best therapies. SUMMARY The important point to remember for all of these conditions is that unlike achalasia, there is no definite pathological correlation to the manometrically observed abnormalities. This therefore makes the management challenging and means that treatment pathways are not as well set out as for some other upper gastrointestinal motility problems.
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Larsen HF, Jensen TSR, Rasmussen L, Ellebæk M, Qvist N. Intramural injection with botulinum toxin significantly elongates the pig esophagus. J Pediatr Surg 2013; 48:2032-5. [PMID: 24094953 DOI: 10.1016/j.jpedsurg.2013.03.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/06/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Surgical treatment of long-gap esophageal atresia (LGEA) is challenging. Methods which facilitate stretching of the esophageal pouches may allow primary anastomosis. Botulinum toxin type A (BTX-A) blocks acetylcholine release in neuromuscular junctions, thereby causing muscle relaxation. We hypothesized that intramural injections with BTX-A into the esophageal wall of piglets would significantly elongate the tissue upon stretch. METHODS Twenty-four piglets were randomized to receive BTX-A of placebo (saline). After one hour, the esophagus was removed en bloc and tested in a stretch-tension device. RESULTS The mean esophageal elongation was 84% (range 83-101) in the BTX-A-group and 65% (50-78) in the control group. The mean difference between the two groups was 18%, which was significant (p < 0.001). CONCLUSION Intramural injections with botulinum toxin type A elongate the esophagus significantly. Clinically, this could be a potential method to achieve primary anastomosis in LGEA. Additional clinical studies are necessary to evaluate the method before it can be generally recommended.
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Abstract
Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.
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Affiliation(s)
- Sami R Achem
- Divisions of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Comments on "Diffuse esophageal spasm in children referred for manometry". J Pediatr Gastroenterol Nutr 2013; 57:e8-9. [PMID: 23518493 DOI: 10.1097/mpg.0b013e3182920747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Bashashati M, Andrews CN. Functional studies of the gastrointestinal tract in adult surgical clinics: when do they help? Int J Surg 2012; 10:280-4. [PMID: 22561737 DOI: 10.1016/j.ijsu.2012.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 04/27/2012] [Indexed: 02/08/2023]
Abstract
Gut motility and visceral sensation are two important components of normal gastrointestinal (GI) tract function. Disordered gut motility and sensation can cause significant symptoms which not only pose a health burden to patients, but may also mimic structural diseases and may generate many surgical referrals from primary care. Unfortunately, diagnostic testing for disorders of function lags well behind that for structural disease. In this article we review common presentations of functional disorders in surgical clinics, and relevant testing modalities.
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