Primary esophageal motility disorders

Utilizing 4D Printing to Design Smart Gastroretentive, Esophageal, and Intravesical Drug Delivery Systems

The breakthrough of 3D printing in biomedical research has paved the way for the next evolutionary step referred to as four dimensional (4D) printing. This new concept utilizes the time as the fourth dimension in addition to the x, y, and z axes with the idea to change the configuration of a printed construct with time usually in response to an external stimulus. This can be attained through the incorporation of smart materials or through a preset smart design. The 4D printed constructs may be designed to exhibit expandability, flexibility, self-folding, self-repair or deformability. This review focuses on 4D printed devices for gastroretentive, esophageal, and intravesical delivery. The currently unmet needs and challenges for these application sites are tried to be defined and reported on published solution concepts involving 4D printing. In addition, other promising application sites that may similarly benefit from 4D printing approaches such as tracheal and intrauterine drug delivery are proposed.

Prevalence of Different Types of Primary Esophageal Motility Disorders and Their Associated Factors in Patients Referring to Shariati Hospital during 2018-2019

BACKGROUND: Esophageal motility disorders (EMDs) are common in patients with dysphagia and are effectively diagnosed with high-resolution manometry (HREM). In this study, we aimed to evaluate the prevalence of different types of primary EMDs in patients referred for HREM and to further investigate the factors associated with EMDs. METHODS: In this cross-sectional study, all patients referred to the endoscopy section of Shariati Hospital during 2018-2019 (279 patients) were subjected to HREM and were evaluated according to their diagnosis, and the effect of each factor and each symptom on motility disorders was investigated. RESULTS: 84.5% (235) of the participants were diagnosed with at least one esophageal motility disorder; of them, achalasia was the most common form (52.6%). None of the predictive factors showed a statistically significant correlation with EMDs. However, regarding the symptoms, regurgitation and nocturnal cough were significantly more common in patients with EMD (P=0.001 and 0.009, respectively). CONCLUSION: This study demonstrates the high prevalence of EMDs in patients undergoing manometry. None of the factors studied, such as age, sex, diabetes, hypothyroidism, smoking, and alcohol and opium consumption, had a statistically significant correlation with EMDs.

Achalasia is associated with a higher incidence of depression in outpatients in Germany

Background and aim

Achalasia represents a chronic motility disorder of the esophagus featuring an impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis. By causing dysphagia, regurgitation, aspiration and chest pain, achalasia might tremendously affect life quality of patients. However, the impact of achalasia on the development of mood disorders including depression has largely remained unclear. The aim of this study was to evaluate the incidence of depression in achalasia patients.

Methods

We analyzed a large primary care cohort database in Germany capturing data from 7.49 million patients.

Results

A total of n = 1,057 patients with achalasia diagnosed between January 2005 and December 2018 were matched to a cohort of n = 3,171 patients without achalasia controlling for age, sex, physician, index year, and the Charlson comorbidity index. Interestingly, while the frequency of depression prior to the diagnosis of achalasia was comparable in both groups, new diagnoses of depression were significantly higher within one year after the diagnosis of achalasia compared to the control group, suggesting a direct and previously unrecognized association between achalasia and depression.

Conclusion

Our data suggest that the clinical management of patients with achalasia should include a careful and structured work-up for mood disorders in order to improve long-term quality of life in these patients.

The incidence of reintervention and reoperation following Heller myotomy across multiple indications

INTRODUCTION

Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State.

METHODS

The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention.

RESULTS

Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively.

CONCLUSION

The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.

Assessment of esophageal motility disorders by real-time MRI

PURPOSE

To investigate imaging findings of esophageal motility disorders on dynamic real-time.

MATERIAL AND METHODS

102 patients with GERD-like symptoms were included in this retrospective study between 2015-2018. Dynamic real-time MRI visualized the transit of a 10 mL pineapple juice bolus through the esophagus and EGJ with a temporal resolution of 40 ms. Dynamic and anatomic parameters were measured by consensus reading. Imaging findings were compared to HRM utilizing the Chicago classification of esophageal motility disorders, v3.0.

RESULTS

All 102 patients completed real-time MRI in a median examination time of 15 min. On HRM, 14 patients presented with disorders with EGJ outlet obstruction (EGJOO) (13.7 %), 7 patients with major disorders of peristalsis (6.9 %), and 32 patients with minor disorders of peristalsis (31.4 %). HRM was normal in 49 patients (48.0 %). Incomplete bolus clearance was significantly more frequent in patients with esophageal motility disorders on HRM than in patients with normal HRM (p = 0.0002). In patients with motility disorders with EGJOO and major disorders of peristalsis, the esophageal diameter tended to be wider (23.6 ± 8.0 vs. 21.2 ± 3.5 mm, p = 0.089) and the sphincter length longer (19.7 ± 7.3 vs. 16.7 ± 3.0 mm, p = 0.091) compared to patients with normal HRM. 3/7 patients with achalasia type II were correctly identified by real-time MRI and one further achalasia type II patient was diagnosed with a motility disorder on MRI films. The other 3/7 patients presented no specific imaging features.

CONCLUSION

Real-time MRI is an auxiliary diagnostic tool for the assessment of swallowing events. Imaging parameters may assist in the detection of esophageal motility disorders.

Esophageal transit scintigraphy in children: a user's guide and pictorial review

Technical and clinical aspects of esophageal transit scintigraphy in pediatric patients are reviewed via several illustrative cases that highlight its utility in evaluating primary and secondary esophageal motility disorders.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Food impaction due to nutcracker esophagus

Nutcracker esophagus is an esophageal motility disorder characterized by the presence of hypertensive contraction waves. These waves can have very high amplitudes, but they maintain a peristaltic pattern and therefore, bolus passage is minimally affected. Esophageal food impactions are rare in nutcracker esophagus. Our patient was a previously asymptomatic man who presented with an esophageal meat impaction due to nutcracker esophagus in which high-resolution manometry played a key role in the diagnosis. Although a rare etiology, nutcracker esophagus can result in esophageal food impaction. High-resolution manometry plays a critical role in the diagnosis of specific motility disorders, even in the setting of minimal symptoms.

Recent progress in treatment of achalasia

Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, absent or decreased esophageal peristaltic waves and synchronous contractions. As the exact pathogenesis of the disease remains unclear, treatment options focus on the alleviation of the functional obstruction caused by lower esophageal sphincter and prevention of gastroesophageal reflux disease at the same time. Treatment modalities include pharmacological therapy, interventional therapy, surgical treatment and spinal rotation massage. This article reviews the latest progress in treatment of achalasia, with particular emphasis on the evolution of main treatments which include endoscopic pneumatic dilation, Heller myotomy and per-oral endoscopic myotomy (POEM).

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Botulinum toxin in the treatment of diffuse esophageal spasm

Diffuse esophageal spasm is a primary esophageal motility disorder. The prevalence is 3-10% in patients with dysphagia and treatment options are limited. This review summarizes the treatment of diffuse esophageal spasm, including pharmacotherapy, endoscopic treatment, and surgical treatment with a special focus on botulinum toxin injection. A PubMed search was performed to identify the literature using the search items diffuse esophageal spasm and treatment. Pharmacotherapy with smooth muscle relaxants, proton pump inhibitors, and antidepressants was suggested from small case series and uncontrolled clinical trials. Endoscopic injection of botulinum toxin is a well-studied treatment option and results in good symptomatic benefit in patients with diffuse esophageal spasm. Surgical treatment was reported in patients with very severe symptoms refractory to pharmacologic treatment. This article summarizes the present knowledge on the treatment of diffuse esophageal spasm with a special emphasis on botulinum toxin injection. Endoscopic injection of botulinum toxin is presently the best studied treatment option but many questions remain unanswered.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Diffuse esophageal spasm: CT findings in seven patients

OBJECTIVE

The purpose of this study was to determine the frequency and appearance of esophageal wall thickening on CT scans in a series of patients with findings of diffuse esophageal spasm on barium studies.

CONCLUSION

CT revealed marked esophageal wall thickening in seven (21%) of 33 patients who had findings of diffuse esophageal spasm on barium studies. CT showed significantly greater esophageal wall thickening in the lower thoracic esophagus 5 cm above the gastroesophageal junction than in the upper thoracic esophagus at the level of the aortic arch or in the midthoracic esophagus at the level of the carina (p < 0.01). This esophageal wall thickening corresponded to the presence of multiple strong nonperistaltic contractions in the lower thoracic esophagus on barium studies. Our findings suggest that diffuse esophageal spasm should be included in the differential diagnosis when CT shows smooth circumferential wall thickening in the lower half of the thoracic esophagus, particularly in elderly patients with dysphagia or chest pain.

Diffuse esophageal spasm

The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Transient failure of opening of the lower oesophageal sphincter on upright oesophagrams: radiographic and clinical findings

The purpose of our study was to determine the frequency, radiographic features, and clinical importance of transient failure of opening of the lower oesophageal sphincter (LOS) on upright double-contrast views of the oesophagus. A computerized search of radiology records identified 16 patients who had transient failure of opening of the LOS on upright views from biphasic oesophagrams or upper gastrointestinal tract examinations using high-density barium but normal opening of the LOS on prone views using low-density barium. The radiographic findings were reviewed and correlated with the clinical and manometric findings. In all cases, barium studies revealed tapered, beaklike narrowing of the distal oesophagus on upright double-contrast views, with a normal-appearing distal oesophagus, normal opening of the LOS, and intact peristalsis on prone single-contrast views. Only seven patients (44%) had dysphagia. Five of these patients had clinical follow-up, and the dysphagia improved or resolved without specific treatment for LOS dysfunction in four. The remaining patient had persistent dysphagia, but this individual had polymyositis as the likely cause for his dysphagia. Manometry revealed incomplete relaxation of the LOS in two patients and normal relaxation in one. Our experience suggests that failure of opening of the LOS may be observed as a transient finding of little clinical importance on upright double-contrast views of the oesophagus using high-density barium, with normal opening of the LOS on prone single-contrast views using low-density barium. It is important to be aware of this finding, so that it is not mistaken for achalasia or other abnormalities of the distal oesophagus.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trails have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2002, Issue 3), MEDLINE (1966 to 2002), CINAHL (1982 to 2002) EMBASE (1980 to 2002), PSYCH Info (1887 to 2002), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to 2002). We also searched citation lists and approached authors.

SELECTION CRITERIA

RCTs with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Eight studies involving 403 randomised participants were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.58 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; the standardized mean difference = 0.85 (95% CI 0.38 to 1.31). However, there was high heterogeneity for this test. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult.

AUTHORS' CONCLUSIONS

Review suggested a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Relationship Between Diffuse Esophageal Spasm and Lower Esophageal Sphincter Dysfunction on Barium Studies and Manometry in 14 Patients

OBJECTIVE

We sought to reassess the function and clinical characteristics of the lower esophageal sphincter in a series of patients with radiographically defined diffuse esophageal spasm.

MATERIALS AND METHODS

In reviewing records in the radiology database at our hospital, we identified 14 patients with diffuse esophageal spasm confirmed on barium studies who also underwent esophageal manometry. The radiographic findings were reviewed and correlated with the manometric findings. Medical records were also reviewed to determine the clinical presentation, treatment, and patient course.

RESULTS

All 14 patients were symptomatic, presenting with dysphagia, chest pain, or both. All the barium studies revealed intermittently absent or weakened peristalsis, with nonperistaltic contractions that were moderate in six patients (43%) and marked in eight patients (57%) (contractions nearly obliterating the lumen in six and completely obliterating the lumen in two). Nine patients (64%) had impaired opening of the lower esophageal sphincter, manifested by beaklike narrowing of the distal esophagus, and five (36%) had normal opening of the lower esophageal sphincter. Manometry revealed abnormal peristalsis in all 14 patients, with repetitive simultaneous contractions in eight (57%) and lower esophageal sphincter dysfunction in 12 (86%). All eight patients with lower esophageal sphincter dysfunction or incomplete relaxation of the lower esophageal sphincter on barium studies or manometry who were treated with the Clostridium botulinum toxin or endoscopic balloon dilatation had a positive response.

CONCLUSION

Our preliminary data show that diffuse esophageal spasm is characterized on barium studies by frequent lower esophageal sphincter dysfunction rather than a classic corkscrew appearance. Barium and manometric studies may have complementary roles in the evaluation of patients with diffuse esophageal spasm.