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Awadhi SA, Miqdady M, Abuzakouk M, Yousef O, Tzivinikos C, Georgopoulos F, Carr S, Sultan A, Bitar R, Dajani AI, Taha M, Alakrad E, Jazzar A, Banama M, Bamakhrama K, Alnahdi N, Elghoudi AA, Azaz A, Gutta R, Fahmy M, Raghib B, Murad S, Abdelmallek M. Expert Recommendations on the Diagnosis of Eosinophilic Esophagitis in the United Arab Emirates. Cureus 2024; 16:e56062. [PMID: 38618346 PMCID: PMC11009821 DOI: 10.7759/cureus.56062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/16/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory esophageal disease presenting as dysphagia to solid food and non-obstructive food impaction. Knowledge gaps exist in its diagnosis and management. These expert recommendations focused on the diagnosis of EoE in the United Arab Emirates. An electronic search of PubMed and Embase databases was used to gather evidence from systematic reviews, randomized controlled trials, consensus papers, and expert opinions from the last five years on the diagnosis of EoE. The evidence was graded using the Oxford system. Literature search findings were shared with the expert panel. A 5-point scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) was used, and a concordance rate of >75% among experts indicated agreement. Using a modified Delphi technique, 18 qualified experts provided 17 recommendations. Eleven statements achieved high agreement, four got moderate agreement, and two got low agreement. Challenges exist in diagnosing EoE, particularly in children. Esophageal biopsies were crucial in diagnosis, irrespective of visible mucosal changes. Further research on diagnostic tools like endoscopic mucosal impedance and biomarkers is needed. Diagnosis relies on esophageal biopsies and symptom-histology correlation; however, tools like EoE assessment questionnaires and endoscopic mucosal impedance could enhance the accuracy and efficiency of EoE diagnosis. The diagnosis of EoE is challenging since the symptoms seldom correlate with the histological findings. Currently, diagnosis is based on patient symptoms and endoscopic and histological findings. Further research into mucosal impedance tests and the role of biomarkers is needed to facilitate diagnosis.
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Affiliation(s)
- Sameer Al Awadhi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Mohamad Miqdady
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Mohamed Abuzakouk
- Allergy and Immunology, Respiratory Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Osama Yousef
- Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Christos Tzivinikos
- Pediatric Gastroenterology, Al Jalila Children's Speciality Hospital, Dubai, ARE
- Pediatric Gastroenterology, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | | | - Stuart Carr
- Immunology and Allergy, Snö Clinics, Abu Dhabi, ARE
| | - Ahmed Sultan
- Gastroenterology and Hepatology, Mediclinic Airport Road Hospital, Abu Dhabi, ARE
| | - Rana Bitar
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | | | - Mazen Taha
- Gastroenterology and Hepatology, Tawam Hospital, Abu Dhabi, ARE
| | - Eyad Alakrad
- Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi, ARE
| | - Ahmad Jazzar
- Gastroenterology and Hepatology, Burjeel Day Surgery Center, Abu Dhabi, ARE
| | - Mohammed Banama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Khaled Bamakhrama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Nawal Alnahdi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | | | - Amer Azaz
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Ravi Gutta
- Immunology, Mediclinic City Hospital, Dubai, ARE
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2
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Müller M, Denzer UW, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0]. Laryngorhinootologie 2023; 102:742-753. [PMID: 37253378 DOI: 10.1055/a-1949-3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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3
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Müller M, Denzer UW, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:284-296. [PMID: 35839796 DOI: 10.1055/a-1833-9366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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4
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Reddy SB, Ketchem CJ, Dougherty MK, Eluri S, Dellon ES. Association between eosinophilic esophagitis and esophageal dysmotility: A systematic review and meta-analysis. Neurogastroenterol Motil 2023; 35:e14475. [PMID: 36168184 DOI: 10.1111/nmo.14475] [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: 07/25/2022] [Revised: 09/03/2022] [Accepted: 09/13/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is conflicting evidence about the association between eosinophilic esophagitis (EoE) and esophageal motility disorders. The aim of this study was to evaluate esophageal manometry findings in EoE. METHODS We conducted a systematic review using PubMed, EMBASE, and Web of Science. All articles from 1990 to 2021 with EoE patients who underwent esophageal manometry were eligible. We also included pertinent abstracts from national conferences from 2015 to 2020. The primary outcomes were the prevalence of specific Chicago 3 Classification (CCv3) diagnoses in EoE, as well as broader categories of non-relaxing lower esophageal sphincter, and major and minor peristaltic disorders. When multiple studies reported a specific outcome, we performed random effects meta-analysis to obtain pooled prevalence of each outcome. To reduce heterogeneity, we restricted meta-analysis to high-resolution manometry (HRM) studies only. KEY RESULTS Of 763 publications identified, 27 original studies met criteria for inclusion, encompassing 706 EoE patients; 14 studies (425 patients) had HRM and underwent meta-analysis. The pooled prevalence of any motility abnormality was 53% (95% CI: 43%-63%), largely comprised of minor motility disorders such as ineffective esophageal motility and fragmented peristalsis. Major motility disorders, classified by CCv3, were less common in EoE, with pooled prevalence of 2% (0%-7%), 10% (5%-16%), and 1% (0%-3%), for achalasia, esophagogastric-junction outflow obstruction, and hypercontractile disorders, respectively. CONCLUSION AND INFERENCES Non-specific motility disorders were common in patients with EoE, but major motility disorders were rare. Further studies are needed to determine the relationship between eosinophilic infiltration and the clinical relevance of abnormal esophageal motility findings in this population.
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Affiliation(s)
- Sumana B Reddy
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Corey J Ketchem
- School of Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael K Dougherty
- School of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Rex Digestive Healthcare, Raleigh, North Carolina, USA
| | - Swathi Eluri
- School of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Evan S Dellon
- School of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,School of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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5
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Wong S, Safaeian R, Zobel J, Holloway RH, Ruszkiewicz A, Nguyen NQ. Increase in distal esophageal wall thickness with time in adult patients with eosinophilic esophagitis. JGH OPEN 2023; 7:178-181. [PMID: 36968573 PMCID: PMC10037037 DOI: 10.1002/jgh3.12866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/22/2022] [Accepted: 01/01/2023] [Indexed: 02/05/2023]
Abstract
Background and Aim Eosinophilic esophagitis (EoE) is a chronic disease which may progress to a fibro-stenotic phenotype due to esophageal sub-epithelial fibrosis. Esophageal wall thickening in patients with EoE has been demonstrated in a few studies using endoscopic ultrasound (EUS). The aim of this study was to longitudinally assess the endoscopic appearance, wall thickness, histology, and dysphagia score of EoE patients. Methods Patients with EoE were recruited and studied between February 2012 and April 2021. Patients were evaluated on two separate occasions at least 12 months apart with endoscopy, EUS, and esophageal mucosal biopsies. The dysphagia score and epidemiology data were also assessed. Results A total of 16 EoE patients were included with a mean follow-up duration of 2.2 ± 1.2 years. In 14/16 (88%) patients, the total wall thickness of the distal esophagus significantly increased (P = 0.0012) as a result of thickening of the muscularis propria (P = 0.0218). However, only 1/14 (7%) patient had an increase in the dysphagia score, while 8/14 (57%) and 5/14 (36%) had a stable and reduced dysphagia score, respectively. No differences were found in the total thickness of other esophageal regions, dysphagia score, endoscopic appearance, and eosinophil count over time. Conclusion Distal esophageal wall thickness increases with time in EoE patients, independent of the dysphagia score and eosinophil count.
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Affiliation(s)
- Stephanie Wong
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
| | - Romina Safaeian
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Joshua Zobel
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Richard H Holloway
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Andrew Ruszkiewicz
- School of Medicine University of Adelaide Adelaide South Australia Australia
- SA Pathology Adelaide South Australia Australia
- School of Pharmacy and Medical Science University of South Australia Adelaide South Australia Australia
- Centre for Cancer Biology Adelaide South Australia Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
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6
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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7
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Wong S, Ellison S, Haj Ali S, Hawkes J, Collinson J, O'Neill T, Ruszkiewicz A, Moore D, Holloway RH, Nguyen NQ. Characteristics and progression of childhood-onset and adult-onset eosinophilic esophagitis. J Gastroenterol Hepatol 2022; 37:69-74. [PMID: 34374118 DOI: 10.1111/jgh.15660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/27/2021] [Accepted: 08/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The prevalence and incidence of eosinophilic esophagitis (EoE) has been increasing over recent years. However, the natural history remains incompletely understood particularly the differences in disease characteristics and progression of childhood-onset and adult-onset EoE. The aim of this study was to evaluate the disease characteristics and progression of childhood-onset and adult-onset EoE. METHODS A cross-sectional, questionnaire-based study, on 87 adults and 67 children from 2 major tertiary hospitals in South Australia was conducted. Data of those who were diagnosed with EoE between 1999 and 2018 were collected and correlated with medical records. RESULTS Of the 87 adults with EoE, 34 (39%) were diagnosed at the age of < 18 years (childhood-onset EoE). Reflux symptoms were more common in childhood-onset EoE, whereas asthma was more common in adult-onset EoE. The median duration of symptoms prior to diagnosis of EoE was > 1-4 years in childhood-onset disease (44%) and ≥ 10 years in adult-onset disease (34%). Food impaction was significantly more common on initial presentation in those with adult-onset EoE, whereas weight loss was more common in childhood-onset EoE. At the time of questionnaire, regurgitation, abdominal pain, and bloating were more common in childhood-onset EoE. Those with childhood-onset EoE were more likely to have multiple symptoms at questionnaire when compared with their adult-onset counterparts. In both groups, 15% (5/34 childhood-onset EoE and 8/53 adult-onset EoE) were asymptomatic at the time of questionnaire. CONCLUSION Childhood-onset EoE appears to be a progressive disease from childhood to adulthood, however with more inflammatory-type symptoms post transition compared to those with adult-onset EoE.
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Affiliation(s)
- Stephanie Wong
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Samuel Ellison
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Sara Haj Ali
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medicine, Al-Balqa Applied University, Salt, Jordan
| | - Joanna Hawkes
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Jane Collinson
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Thomas O'Neill
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Andrew Ruszkiewicz
- Department of Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Moore
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Richard H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
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8
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Schizas D, Syllaios A, Vailas M, Sotiropoulou M, Triantafyllou T, Tsapralis D, Papanikolaou IS, Theodorou D. Eosinophilic Esophagitis and Achalasia: Two Distinct Nosologic Entities or a Possible Etiopathogenic Association? Dig Dis 2021; 39:553-560. [PMID: 33647902 DOI: 10.1159/000515520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite the fact that researchers have made significant progress in elucidating the pathophysiology of esophageal diseases, the understanding of esophageal motility alterations in patients with eosinophilic esophagitis (EoE) is in its infancy and current published medical literature remains rather scarce on this topic. A growing body of scientific data regarding associations between esophageal motor disorders, such as achalasia and EoE, exists nowadays. SUMMARY It seems that the association of EoE and achalasia does not constitute a cause and effect relationship, as it is not clear whether esophageal motility abnormalities are the result of EoE or vice versa. As such, there is no universally accepted treatment algorithm for patients presenting with both of these entities. Key Messages: The aim of this article is to review the existing data on achalasia-like motility disorders in patients with EoE, highlighting a possible association between these 2 esophageal disorders. Moreover, we seek to describe the clinical presentation in such cases, diagnostic modalities to be used, and current treatment strategies in patients suspected to suffer from both disorders.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Athanasios Syllaios
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Michail Vailas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Maria Sotiropoulou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Tania Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | | | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine and Research Institute, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
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9
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Tom K, Mehta BK, Hoffmann A, Aren K, Carns M, Lee J, Martyanov V, Popovich D, Kosarek N, Wood T, Brenner D, Carlson DA, Ostilla L, Willcocks E, Bryce P, Wechsler JB, Whitfield ML, Hinchcliff M. Mast Cell Activation in the Systemic Sclerosis Esophagus. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 6:77-86. [PMID: 34179507 DOI: 10.1177/2397198320941322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Previously, we discovered similar esophageal gene expression patterns in patients with systemic sclerosis (SSc) and eosinophilic esophagitis (EoE) where eosinophil/mast cell-targeted therapies are beneficial. Because SSc and EoE patients experience similar esophageal symptoms, we hypothesized that eosinophil/mast cell-directed therapy may potentially benefit SSc patients. Herein, we determine the association between esophageal mast cell quantities, gene expression and clinical parameters in order to identify SSc patients who may benefit from eosinophil/mast cell-directed therapy. Methods Esophageal biopsies from SSc patients and healthy participants were stained for tryptase, a mast cell marker, and associations with relevant clinical parameters including 24h esophageal pH testing were assessed. Intra-epithelial mast cell density was quantified by semi-automated microscopy. Microarray data were utilized for functional and gene set enrichment analyses and to identify intrinsic subset (IS) assignment, an SSc molecular classification system that includes inflammatory, proliferative, limited and normal-like subsets. Results Esophageal biopsies from 40 SSc patients (39 receiving proton pump inhibition) and eleven healthy participants were studied. Mast cell numbers in both the upper esophagus (rs = 0.638, p = 0.004) and the entire (upper + lower) esophagus (rs = 0.562, p = 0.019) significantly correlated with acid exposure time percentage. The inflammatory, fibroproliferative, and normal-like ISs originally defined in skin biopsies were identified in esophageal biopsies. Although esophageal mast cell numbers in SSc patients and healthy participants were similar, gene expression for mast cell-related pathways showed significant upregulation in the inflammatory IS of SSc patients compared to patients classified as proliferative or normal-like. Discussion Esophageal mast cell numbers are heterogeneous in SSc patients and may correlate with acid exposure. Patients with inflammatory IS profiles in the esophagus demonstrate more tryptase staining. Mast cell targeted therapy may be a useful therapeutic approach in SSc patients belonging to the inflammatory IS, but additional studies are warranted.
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Affiliation(s)
- Kevin Tom
- Midwestern University, Chicago College of Osteopathic Medicine, 555 31 Street, Downers Grove, IL 60515.,Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, McGaw Pavilion, 240 E. Huron Street, Suite M-300
| | - Bhaven K Mehta
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Aileen Hoffmann
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, McGaw Pavilion, 240 E. Huron Street, Suite M-300
| | - Kathleen Aren
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, McGaw Pavilion, 240 E. Huron Street, Suite M-300
| | - Mary Carns
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, McGaw Pavilion, 240 E. Huron Street, Suite M-300
| | - Jungwha Lee
- Department of Preventive Medicine, 680 N. Lake Shore Drive, Suite 1400.,Institute for Public Health and Medicine, 633 N. St. Clair Street, 18th Floor
| | - Viktor Martyanov
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Dillon Popovich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Noelle Kosarek
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Tammara Wood
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Darren Brenner
- Division of Gastroenterology, 676 N. St. Clair Street, Suite 1400
| | - Dustin A Carlson
- Division of Gastroenterology, 676 N. St. Clair Street, Suite 1400
| | - Lorena Ostilla
- Division of Allergy and Immunology, 240 E. Huron Street, McGaw Pavilion, Suite M-300, Chicago, IL 60611
| | - Emma Willcocks
- Division of Allergy and Immunology, 240 E. Huron Street, McGaw Pavilion, Suite M-300, Chicago, IL 60611
| | - Paul Bryce
- Division of Allergy and Immunology, 240 E. Huron Street, McGaw Pavilion, Suite M-300, Chicago, IL 60611.,Northwestern University Feinberg School of Medicine, Department of Pediatrics, Division of Gastroenterology, Hepatology & Nutrition, 225 E. Chicago, Box 65, Chicago, IL 60611.,Immunology & Inflammation Therapeutic Area, Sanofi US, Cambridge, MA 02139
| | - Joshua B Wechsler
- Division of Allergy and Immunology, 240 E. Huron Street, McGaw Pavilion, Suite M-300, Chicago, IL 60611.,Northwestern University Feinberg School of Medicine, Department of Pediatrics, Division of Gastroenterology, Hepatology & Nutrition, 225 E. Chicago, Box 65, Chicago, IL 60611
| | - Michael L Whitfield
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Monique Hinchcliff
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, McGaw Pavilion, 240 E. Huron Street, Suite M-300.,Yale School of Medicine, Department of Medicine, Section of Rheumatology, Allergy & Immunology, 300 Cedar Street, The Anylan Center, PO BOX 208031, New Haven, CT 06473
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10
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Taft TH, Kern E, Starkey K, Craft J, Craven M, Doerfler B, Keefer L, Kahrilas P, Pandolfino J. The dysphagia stress test for rapid assessment of swallowing difficulties in esophageal conditions. Neurogastroenterol Motil 2019; 31:e13512. [PMID: 30474165 PMCID: PMC6386586 DOI: 10.1111/nmo.13512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/09/2018] [Accepted: 10/19/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Esophageal dysphagia is a common symptom in gastroenterology practice. Current rapid assessment tools are limited to oropharyngeal dysphagia and do not translate well to esophageal conditions. We aim to create a novel tool, the dysphagia stress test (DST), to evaluate swallowing in patients with esophageal disease characterized by dysphagia. METHODS Adults with eosinophilic esophagitis (EoE), gastroesophageal reflux disease (GERD), achalasia, and dysphagia not otherwise specified (NOS) participated. Patient controls with non-esophageal diagnoses and healthy controls were also recruited. Participants completed the DST with five bolus challenges: water, applesauce, rice, bread, barium tablet and rated their swallowing difficulty and pain. A study clinician observed and documented water use and refusal of any challenges. Participants also completed measures of esophageal symptoms, hypersensitivity, and symptom anxiety to evaluate the DST validity. Collinearity of bolus challenges guided item reduction. KEY RESULTS A total of 132 subjects participated. Both control groups and GERD patients had the best swallowing ability, while achalasia, EOE, and dysphagia NOS scored poorer. About 90% of patients were able to attempt or pass each of the bolus challenges, suggesting high acceptability. Construct validity of the DST is evidenced by modest negative correlations with symptom severity, hypersensitivity, and anxiety. The DST does not appear to be influenced by brain-gut processes. Applesauce, rice, and bread demonstrated collinearity; thus, the DST was reduced to three challenges. CONCLUSIONS & INFERENCES The DST is the first rapid assessment tool designed for gastroenterology clinics with direct observation of swallowing ability across several conditions to mitigate issues related to patient self-report of esophageal symptoms.
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Affiliation(s)
- Tiffany H Taft
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Emily Kern
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Kristen Starkey
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Jenna Craft
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Meredith Craven
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Bethany Doerfler
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - Laurie Keefer
- Icahn School of Medicine, Mount Sinai Medical Center, Susan and Leonard Feinstein IBD Center
| | - Peter Kahrilas
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
| | - John Pandolfino
- Northwestern University Feinberg School of Medicine, Division of Gastroenterology & Hepatology
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11
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Sallis BF, Acar U, Hawthorne K, Babcock SJ, Kanagaratham C, Goldsmith JD, Rosen R, Vanderhoof JA, Nurko S, Fiebiger E. A Distinct Esophageal mRNA Pattern Identifies Eosinophilic Esophagitis Patients With Food Impactions. Front Immunol 2018; 9:2059. [PMID: 30455683 PMCID: PMC6230678 DOI: 10.3389/fimmu.2018.02059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/21/2018] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE), a Th2-type allergic immune disorder characterized by an eosinophil-rich esophageal immune infiltrate, is often associated with food impaction (FI) in pediatric patients but the molecular mechanisms underlying the development of this complication are not well understood. We aim to identify molecular pathways involved in the development of FI. Due to large variations in disease presentation, our analysis was further geared to find markers capable of distinguishing EoE patients that are prone to develop food impactions and thus expand an established medical algorithm for EoE by developing a secondary analysis that allows for the identification of patients with food impactions as a distinct patient population. To this end, mRNA patterns from esophageal biopsies of pediatric EoE patients presenting with and without food impactions were compared and machine learning techniques were employed to establish a diagnostic probability score to identify patients with food impactions (EoE+FI). Our analysis showed that EoE patients with food impaction were indistinguishable from other EoE patients based on their tissue eosinophil count, serum IgE levels, or the mRNA transcriptome-based p(EoE). Irrespectively, an additional analysis loop of the medical algorithm was able to separate EoE+FI patients and a composite FI-score was established that identified such patients with a sensitivity of 93% and a specificity of 100%. The esophageal mRNA pattern of EoE+FI patients was typified by lower expression levels of mast cell markers and Th2 associated transcripts, such as FCERIB, CPA3, CCL2, IL4, and IL5. Furthermore, lower expression levels of regulators of esophageal motility (NOS2 and HIF1A) were detected in EoE+FI. The EoE+FI -specific mRNA pattern indicates that impaired motility may be one underlying factor for the development of food impactions in pediatric patients. The availability of improved diagnostic tools such as a medical algorithm for EoE subpopulations will have a direct impact on clinical practice because such strategies can identify molecular inflammatory characteristics of individual EoE patients, which, in turn, will facilitate the development of individualized therapeutic approaches that target the relevant pathways affected in each patient.
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Affiliation(s)
- Benjamin F. Sallis
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Utkucan Acar
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Kelsey Hawthorne
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
| | - Stephen J. Babcock
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Cynthia Kanagaratham
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | | | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
- Department of Pathology, Boston Children's Hospital, Boston, MA, United States
| | - Jon A. Vanderhoof
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
| | - Edda Fiebiger
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
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12
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Wong S, Ruszkiewicz A, Holloway RH, Nguyen NQ. Gastro-oesophageal reflux disease and eosinophilic oesophagitis: What is the relationship? World J Gastrointest Pathophysiol 2018; 9:63-72. [PMID: 30386667 PMCID: PMC6209579 DOI: 10.4291/wjgp.v9.i3.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/17/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic oesophagitis (EoE) and gastro-oesophageal reflux disease (GORD) are the most common causes of chronic oesophagitis and dysphagia associated with oesophageal mucosal eosinophilia. Distinguishing between the two is imperative but challenging due to overlapping clinical and histological features. A diagnosis of EoE requires clinical, histological and endoscopic correlation whereas a diagnosis of GORD is mainly clinical without the need for other investigations. Both entities may exhibit oesophageal eosinophilia at a similar level making a histological distinction between them difficult. Although the term proton-pump inhibitor responsive oesophageal eosinophilia has recently been retracted from the guidelines, a relationship between EoE and GORD still exists. This relationship is complex as they may coexist, either interacting bidirectionally or are unrelated. This review aims to outline the differences and potential relationship between the two conditions, with specific focus on histology, immunology, pathogenesis and treatment.
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Affiliation(s)
- Stephanie Wong
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Andrew Ruszkiewicz
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Anatomical Pathology, SA Pathology, Adelaide SA 5000, Australia
| | - Richard H Holloway
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Nam Q Nguyen
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
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13
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Abstract
PURPOSE OF REVIEW This review addresses the similarities and differences between the spastic esophageal disorders, including jackhammer esophagus, distal esophageal spasm (DES), and type III (spastic) achalasia. The pathophysiology, diagnosis, and treatment of each separate disorder are discussed herein, with an emphasis on overlapping and discordant features. RECENT FINDINGS The Chicago Classification is a hierarchical organizational scheme for esophageal motility disorders, currently in its third iteration, with direct impact on the definitions of these three disorders. Complementary diagnostic tools such as impedance planimetry and novel manometric parameters continue to evolve. The suite of potential treatments for these disorders is also expanding, with progressive interest in the role of peroral endoscopic myotomy alongside established pharmacologic and mechanical interventions. Although jackhammer esophagus, distal esophageal spasm, and type III achalasia frequently overlap in terms of their clinical presentation and available management approaches, the divergences in their respective diagnostic criteria suggest that additional study may reveal additional mechanistic distinctions that lead in turn to further refinements in therapeutic decision-making.
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