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Ugwuegbu O, Shibli F, Kim Y, Rangan V, Kurin M, Ayoub F, Ganocy S, Kavitt R, Fass R. The Impact of Chronic Cannabis Use on Esophageal Motility in Patients Referred for Esophageal Manometry. J Clin Gastroenterol 2024; 58:342-348. [PMID: 37436840 DOI: 10.1097/mcg.0000000000001887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/21/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Tetrahydrocannabinol, the main psychoactive compound in cannabis, binds with high affinity to the cannabinoid 1 receptor. Small randomized controlled studies using conventional manometry have shown that the cannabinoid 1 receptor can modulate esophageal function, namely transient lower esophageal sphincter relaxation frequency and lower esophageal sphincter tone. The effect of cannabinoids on esophageal motility in patients referred for esophageal manometry has not been fully elucidated using high-resolution esophageal manometry (HREM). We aimed to characterize the clinical effect of chronic cannabis use on esophageal motility utilizing HREM. METHODS Patients who underwent HREM from 2009 to 2019 were identified at 4 academic medical centers. The study group consisted of patients with a noted history of chronic cannabis use, a diagnosis of cannabis-related disorder, or a positive urine toxicology screen. Age and gender-matched patients with no history of cannabis use were selected to form the control group. Data on HREM metrics based on the Chicago classification V3, and the prevalence of esophageal motility disorders were compared. Confounding effects of BMI and medications on esophageal motility were adjusted for. RESULTS Chronic cannabis use was found to be an independent negative predictor of weak swallows (β=-8.02, P =0.0109), but not a predictor of failed swallows ( P =0.6890). The prevalence of ineffective esophageal motility was significantly lower in chronic cannabis users compared with nonusers (OR=0.44, 95% CI 0.19-0.93, P =0.0384). There was no significant difference in the prevalence of other esophageal motility disorders between the 2 cohorts. In patients with dysphagia as their primary indication for HREM, chronic cannabis use was found to be independently associated with increased median integrated relaxation pressure (β=6.638, P =0.0153) and increased mean lower esophageal sphincter resting pressure (β=10.38, P =0.0084). CONCLUSIONS Chronic cannabis use is associated with decreased weak swallows and reduced prevalence of ineffective esophageal motility in patients referred for esophageal manometry. In patients referred for dysphagia, chronic cannabis use is associated with increased integrated relaxation pressure and lower esophageal sphincter resting pressure, though not to levels above the normal range.
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Affiliation(s)
- Obinna Ugwuegbu
- Case Western Reserve University, School of Medicine, Cleveland, OH
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Fahmi Shibli
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Yeseong Kim
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Vikram Rangan
- Beth Israel Deaconess Medical Center. Digestive Disease Center, Harvard University, Boston, MA
| | - Michael Kurin
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
- University Hospitals Cleveland Medical Center Department of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, OH
| | - Fares Ayoub
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, IL
| | - Stephen Ganocy
- Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
| | - Robert Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, IL
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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Lechien JR. Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date. Clin Interv Aging 2022; 17:1625-1633. [PMID: 36411760 PMCID: PMC9675328 DOI: 10.2147/cia.s371992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose The clinical presentation and therapeutic outcomes of elderly patients may be different from those in younger populations, leading to additional diagnostic and therapeutic difficulties. The present study reviewed the findings on the epidemiology, and clinical, diagnostic, and therapeutic outcomes of elderly patients with laryngopharyngeal reflux (LPR). Methods A PubMed, Cochrane Library, and Scopus literature search was conducted on the epidemiological, clinical, diagnostic, and therapeutic findings of elderly LPR patients. Findings The prevalence of LPR in the elderly population remains unknown. From a clinical standpoint, older LPR patients report overall lower symptom scores and related quality-of-life outcomes at the time of the diagnosis. The required treatment time to obtain symptom relief appears to be longer in older compared with younger patients. Particular attention needs to be paid to prolonged medication use because the elderly population is characterized by polypharmacy and there is a higher risk of proton-pump inhibitor (PPI) interactions and adverse events. The plasma clearance of most PPIs is reduced with age, which must be considered by practitioners in the prescription of antireflux therapy. Conclusion The clinical presentation and treatment efficacy of elderly LPR patients differ from those in younger patients. Practitioners need to carefully consider the risk of drug interactions and adverse events in elderly patients.
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Affiliation(s)
- Jerome R Lechien
- Polyclinic of Poitiers, Elsan Hospital, Poitiers, France
- Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology–Head and Neck Surgery, EpiCURA Hospital, University of Mons, Baudour, Belgium
- Correspondence: Jerome R Lechien, Department of Otolaryngology–Head and Neck Surgery, EpiCURA Hospital, University of Mons, Rue L. Cathy, Mons, Belgium, Tel +32 65 37 35 84, Email
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Sandoval-Munoz CP, Haidar ZS. Neuro-Muscular Dentistry: the "diamond" concept of electro-stimulation potential for stomato-gnathic and oro-dental conditions. Head Face Med 2021; 17:2. [PMID: 33499906 PMCID: PMC7836574 DOI: 10.1186/s13005-021-00257-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 01/19/2021] [Indexed: 01/17/2023] Open
Abstract
Oro-Pharyngeal Dysphagia - or simply dysphagia - is the difficulty (persistent) in swallowing/passing food and/or liquid from the mouth to the pharynx into the esophagus and finally the stomach; a deglutition disorder (a symptom, by definition, often due to neuro-degenerative/−muscular, drug-induced or localized structural pathologies such as head and neck tumors, lesions and associated surgical and/or radiation injuries) linked to severe consequences on Quality of Life (QoL), including malnutrition, dehydration, and even sudden death. Likewise, Temporo-Mandibular Jaw and Joint disorder(s) – or simply TMD – is a multifactorial etiological condition, regularly encountered in the dental office. Whether due to malocclusion, bruxism, stress and/or trauma, TMD destabilizes the whole cranio-mandibular system structurally and functionally, via affecting mastication, teeth, supporting structures, comfort and aesthetics, and thus, QoL, again. While several treatment regimens do exist for such conditions, some of which have been standardized for use over the years, most continue to lack proper evidence-based literature support. Hence, (1) caution is to be exercised; and (2) the need for alternative therapeutic strategies is amplified, subsequently, the door for innovation is wide open. Indeed, neuromuscular electrical stimulation or “NMES”, is perhaps a fine example. Herein, we present the interested oro-dental health care provider with an up-dated revision of this therapeutic modality, its potential benefits, risks and concerns, to best handle the dysphagic patient: an intra-disciplinary approach or strategy bridging contemporary dentistry with speech and language therapy; a rather obscure and un-discovered yet critical allied health profession. A pre-clinical and clinical prospectus on employing inventive NMES-based regimens and devices to manage TMD is also highlighted.
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Affiliation(s)
- Catalina P Sandoval-Munoz
- BioMAT'X (Laboratorio de Biomateriales, Farmacéuticos y Bioingeniería de Tejidos Cráneo Máxilo-Facial), Universidad de los Andes, Mons. Álvaro del Portillo 12.455 - Las Condes, Santiago, Chile
| | - Ziyad S Haidar
- BioMAT'X (Laboratorio de Biomateriales, Farmacéuticos y Bioingeniería de Tejidos Cráneo Máxilo-Facial), Universidad de los Andes, Mons. Álvaro del Portillo 12.455 - Las Condes, Santiago, Chile. .,Programa de Doctorado en BioMedicina, Facultad de Medicina, Universidad de los Andes, Mons. Álvaro del Portillo 12.455 - Las Condes, Santiago, Chile. .,Centro de Investigación e Innovación Biomédica (CIIB), Universidad de los Andes, Mons. Álvaro del Portillo 12.455 - Las Condes, Santiago, Chile. .,Facultad de Odontología, Universidad de los Andes, Mons. Álvaro del Portillo 12.455 - Las Condes, Santiago, Chile.
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Treatment for Adults. Dysphagia 2021. [DOI: 10.1016/b978-0-323-63648-3.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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Schlottmann F, Shaheen NJ, Madanick RD, Patti MG. The role of Heller myotomy and POEM for nonachalasia motility disorders. Dis Esophagus 2017; 30:1-5. [PMID: 28375487 DOI: 10.1093/dote/dox003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/05/2017] [Indexed: 12/11/2022]
Abstract
The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.
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Affiliation(s)
- F Schlottmann
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
| | - N J Shaheen
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - R D Madanick
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - M G Patti
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
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Ruiz de León San Juan A, Ciriza de los Ríos C, Pérez de la Serna Bueno J, Canga Rodríguez-Valcárcel F, Estremera Arévalo F, García Sánchez R, Huamán Ríos JW, Pérez Fernández MT, Santander Vaquero C, Serra Pueyo J, Sevilla Mantilla C, Barba Orozco E, Bosque López MJ, Casabona Francés S, Carrión Bolorino S, Castillo Grau P, Delgado Aros S, Domínguez Carbajo AB, Fernández Orcajo P, García-Lledó J, Gigantó Tomé F, Iglesias Picazo R, Lacima Vidal G, López López P, Llabrés Rosselló M, Mas Mercader P, Mego Silva M, Mendarte Barrenetxea MU, Miliani Molina C, Oreja Arrayago M, Sánchez Ceballos F, Sánchez Prudencio S. Practical aspects of high resolution esophageal manometry. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:91-105. [DOI: 10.17235/reed.2016.4441/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Felix VN, DeVault K, Penagini R, Elvevi A, Swanstrom L, Wassenaar E, Crespin OM, Pellegrini CA, Wong R. Causes and treatments of achalasia, and primary disorders of the esophageal body. Ann N Y Acad Sci 2013; 1300:236-249. [PMID: 24117646 DOI: 10.1111/nyas.12254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).
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Affiliation(s)
| | - Kenneth DeVault
- Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | - Roberto Penagini
- Università degli Studi di Milano and Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Elvevi
- Università degli Studi di Milano and Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Eelco Wassenaar
- Department of Surgery, University of Washington, Seattle, Washington
| | - Oscar M Crespin
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Roy Wong
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Abstract
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.
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Affiliation(s)
- M Bashashati
- Division of Gastroenterology, Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada
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Herbella FA, Raz DJ, Nipomnick I, Patti MG. Primary Versus Secondary Esophageal Motility Disorders: Diagnosis and Implications for Treatment. J Laparoendosc Adv Surg Tech A 2009; 19:195-8. [DOI: 10.1089/lap.2008.0317] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fernando A.M. Herbella
- Department of Surgery, University of California—San Francisco, San Francisco, California
| | - Dan J. Raz
- Department of Surgery, University of California—San Francisco, San Francisco, California
| | - Ian Nipomnick
- Department of Surgery, University of California—San Francisco, San Francisco, California
| | - Marco G. Patti
- Department of Surgery, University of California—San Francisco, San Francisco, California
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Naftali T, Levit T, Pomeranz I, Benjaminov FS, Konikoff FM. Nonspecific esophageal motility disorders may be an early stage of a specific disorder, particularly achalasia. Dis Esophagus 2009; 22:611-5. [PMID: 19302217 DOI: 10.1111/j.1442-2050.2009.00962.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The clinical significance of nonspecific esophageal motility disorder (NEMD) is unclear. Our aim was to investigate the natural history of NEMD. All manometries performed at Meir Hospital from 1997 to 2004 and diagnosed as NEMD were reviewed. Manometric criteria for NEMD included either low-amplitude peristalsis, nonprogression of peristalsis, prolonged retrograde or triple-peaked waves, or incomplete relaxation of the lower sphincter. Patients determined to have NEMD were contacted and asked to complete a questionnaire and undergo a second manometry. NEMD had been diagnosed in 137 patients. Upon review of manometry results, 65 patients were eligible for the study (36 men and 29 women). The other 72 patients did not have NEMD when we reviewed their manometry tracing, applying strict criteria as specified in Table 1. The average age was 64 +/- 16 years (range 24-83 years). The average follow-up period was 7 +/- 2 years. All 65 patients were symptomatic at their initial prestudy visit. By the second visit, symptoms had resolved in 33 (51%) patients and improved in 13 (19%). Dysphagia, chest pain, and food regurgitation had improved, whereas heartburn and respiratory symptoms had not. Of 37 patients with triple-peaked waves, only 11 (30%) had improved clinically. Of the 65 study patients, 17 (26%) had a second manometry during the study, which was normal in 2 (12%), unchanged in 11 (69%), and revealed achalasia in 4 (23%), representing 6% of all study patients. NEMD is generally a benign disorder that improves clinically in most cases. Nevertheless, in about 6% of patients, NEMD may evolve into achalasia.
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Affiliation(s)
- T Naftali
- Department of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, Israel.
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Kim HS, Park H, Lim JH, Choi SH, Park C, Lee SI, Conklin JL. Morphometric evaluation of oesophageal wall in patients with nutcracker oesophagus and ineffective oesophageal motility. Neurogastroenterol Motil 2008; 20:869-76. [PMID: 18452508 DOI: 10.1111/j.1365-2982.2008.01128.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The pathogenesis of nutcracker oesophagus (NE) and ineffective oesophageal motility (IEM) is unclear. Damage to the enteric nervous system or smooth muscle can cause oesophageal dysmotility. We tested the hypothesis that NE and IEM are associated with abnormal muscular or neural constituents of the oesophageal wall. Oesophageal manometry was performed in patients prior to total gastrectomy for gastric cancer. The oesophageal manometries were categorized as normal (n = 7), NE (n = 13), or IEM (n = 5). Histologic examination of oesophageal tissue obtained during surgery was performed after haematoxylin and eosin (H&E) and trichrome staining. Oesophageal innervation was examined after immunostaining for protein gene product-9.5 (PGP-9.5), choline acetyltransferase (ChAT) and neuronal nitric oxide synthase (nNOS). There were no significant differences in inner circular smooth muscle thickness or degree of fibrosis among the three groups. Severe muscle fibre loss was found in four of five patients with IEM. The density of PGP-9.5-reactive neural structures was not different among the three groups. The density of ChAT immunostaining in the myenteric plexus (MP) was significantly greater in patients with NE (P < 0.05) and the density of nNOS immunostaining in the circular muscle (CM) was significantly greater in IEM patients (P < 0.05). The ChAT/nNOS ratio in both MP and CM was significantly greater in NE patients. NE may result from an imbalance between the excitatory and inhibitory innervation of the oesophagus, because more than normal numbers of ChAT-positive myenteric neurones are seen in NE. Myopathy and/or increased number of nNOS neurones may contribute to the hypocontractile motor activity of IEM.
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Affiliation(s)
- H S Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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14
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Surgical treatment of primary esophageal motility disorders. J Gastrointest Surg 2008; 12:604-8. [PMID: 17999124 DOI: 10.1007/s11605-007-0379-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 09/26/2007] [Indexed: 01/31/2023]
Abstract
Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.
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15
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Secondary Achalasia and Other Esophageal Motility Disorders After Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease. AJR Am J Roentgenol 2007; 189:1464-8. [DOI: 10.2214/ajr.07.2582] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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16
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Kamberoglou DK, Xirouchakis ES, Margetis NG, Delaporta EE, Zambeli EP, Doulgeroglou VG, Tzias VD. Correlation between esophageal contraction amplitude and lower esophageal sphincter pressure in patients with nutcracker esophagus. Dis Esophagus 2007; 20:151-4. [PMID: 17439599 DOI: 10.1111/j.1442-2050.2007.00661.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutcracker esophagus (NE) is a primary esophageal motility disorder characterized by high-wave amplitude at the distal esophagus. The aim of this study was to analyze patients with NE and determine the relationship between distal esophageal contraction amplitude and lower esophageal sphincter (LES) pressure. Esophageal manometry tracings of patients with NE, defined as the presence of distal contraction amplitude of more than 182 mmHg after wet swallow, were analyzed. LES pressure was measured as the mean end-expiratory value. Spearman's correlation coefficient analysis was used to compare esophageal contraction amplitude with LES pressure. This comparison was also performed in patients with isolated hypertensive LES (HLES) and in subjects with normal manometry. Forty patients (25 female, 15 male; mean age 54 years) with NE were included in the study. Mean (SD) distal esophageal contraction amplitude was 230 (35.7) mmHg and mean LES pressure was 27.3 (5.7) mmHg. Esophageal contraction amplitude showed a positive correlation with LES pressure (r = 0.49, P < 0.01). In contrast, no correlation was found in patients with HLES (r = 0.21, P > 0.05) and in those with a normal manometric study (r = 0.18, P > 0.05). It is concluded that in patients with nutcracker esophagus a positive correlation exists between distal esophageal contraction amplitude and LES pressure, suggesting a diffuse hypertensive pattern involving smooth muscle at the distal esophagus and adjacent LES.
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Affiliation(s)
- D K Kamberoglou
- Department of GI Endoscopy, 1st IKA Hospital, Athens, Greece.
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17
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Neuhuber WL, Raab M, Berthoud HR, Wörl J. Innervation of the mammalian esophagus. ADVANCES IN ANATOMY EMBRYOLOGY AND CELL BIOLOGY 2006. [PMID: 16573241 DOI: 10.1007/978-3-540-32948-0_1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Understanding the innervation of the esophagus is a prerequisite for successful treatment of a variety of disorders, e.g., dysphagia, achalasia, gastroesophageal reflux disease (GERD) and non-cardiac chest pain. Although, at first glance, functions of the esophagus are relatively simple, their neuronal control is considerably complex. Vagal motor neurons of the nucleus ambiguus and preganglionic neurons of the dorsal motor nucleus innervate striated and smooth muscle, respectively. Myenteric neurons represent the interface between the dorsal motor nucleus and smooth muscle but they are also involved in striated muscle innervation. Intraganglionic laminar endings (IGLEs) represent mechanosensory vagal afferent terminals. They also establish intricate connections with enteric neurons. Afferent information is implemented by the swallowing central pattern generator in the brainstem, which generates and coordinates deglutitive activity in both striated and smooth esophageal muscle and orchestrates esophageal sphincters as well as gastric adaptive relaxation. Disturbed excitation/inhibition balance in the lower esophageal sphincter results in motility disorders, e.g., achalasia and GERD. Loss of mechanosensory afferents disrupts adaptation of deglutitive motor programs to bolus variables, eventually leading to megaesophagus. Both spinal and vagal afferents appear to contribute to painful sensations, e.g., non-cardiac chest pain. Extrinsic and intrinsic neurons may be involved in intramural reflexes using acetylcholine, nitric oxide, substance P, CGRP and glutamate as main transmitters. In addition, other molecules, e.g., ATP, GABA and probably also inflammatory cytokines, may modulate these neuronal functions.
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18
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Vallot T, Merrouche M. [Diagnosis of dysphagia with no apparent cause]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:399-407. [PMID: 16633305 DOI: 10.1016/s0399-8320(06)73194-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- Thierry Vallot
- Hépato-Gastroentérologie, CHU Bichat-Claude Bernard, Paris
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19
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Abstract
Achalasia is a primary motility disorder of the esophagus that causes dysphagia. Normal esophageal motility and lower esophageal sphincter (LES) function can not be restored; thus treatment is directed at decreasing the pressure or disrupting the muscle fibers of the LES to allow passage of ingested material. Effective therapy for achalasia can be broadly characterized as surgery based or endoscopy based. Medications (calcium channel blockers and nitrate derivatives) do not provide adequate relief of dysphagia and have substantial side effects, and thus are rarely used as long-term therapy. Botulinum toxin injection, a recently introduced endoscopic therapy, enjoyed much enthusiasm initially but was shown to have only transient effect and is now recommended only for poor operative candidates. The mainstay of therapy remains endoscopic dilation or laparoscopic esophagomyotomy (LEM) combined with an antireflux procedure. We have found that patients who can tolerate a laparoscopic abdominal surgery are best served with an LEM and Toupet (270 degrees ) posterior fundoplication. This provides good or excellent relief of dysphagia in 90% to 95% of patients with very little morbidity.
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Affiliation(s)
- Jedediah A Kaufman
- Department of Surgery, University of Washington, 1959 NE Pacific St., Box 356410, Seattle, WA 98195-6410, USA
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20
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Abstract
Gastroesophageal reflux disease (GERD) is one of the most common diagnoses in daily practice. Diagnosis can be made on symptom evaluation, on pH-monitoring or on endoscopic findings. In contrast to commonly held opinion there is no strong evidence that lifestyle factors are a dominant factor in the pathophysiology of GERD. The various agents currently used for treatment of GERD include mucoprotective substances, antacids, H(2)-blockers and proton pump inhibitors. This article gives an overview of the pharmacological management of GERD and focuses on the differential therapy of endoscopy-negative GERD, GERD with esophagitis and maintenance therapy.
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Affiliation(s)
- M Storr
- Department of Internal Medicine II - Standort Grosshadern, Ludwig-Maximilians University, Munich, Germany.
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21
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Huffman JC, Stern TA. The use of benzodiazepines in the treatment of chest pain: a review of the literature. J Emerg Med 2004; 25:427-37. [PMID: 14654185 DOI: 10.1016/j.jemermed.2003.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Benzodiazepines, although not listed in the American Heart Association's guidelines for the treatment of chest pain, are often used to provide symptomatic relief to patients who experience chest pain. To investigate the utility of benzodiazepines in the treatment of chest pain, the pharmacologic actions and cardiovascular effects of benzodiazepines were reviewed. In addition, a literature search regarding the use of benzodiazepines to treat patients with chest pain was conducted. The results indicated that benzodiazepines reduce anxiety, pain, and cardiovascular activation. Benzodiazepines amplify gamma-aminobutyric acid (GABA) throughout the central nervous system, and act more peripherally to reduce catecholamines. In addition, preliminary evidence indicates that benzodiazepines may cause coronary vasodilatation, prevent dysrhythmias, and block platelet aggregation, though further study is needed. Both non-cardiac chest pain (associated with musculoskeletal, esophageal, neurologic, and psychiatric conditions) and cardiac chest pain (associated with acute and chronic myocardial ischemia) seem to be effectively treated with benzodiazepines. Benzodiazepines are safe and well tolerated when administered alone or in combination with other medications. Moreover, the risk of dependence is minimal when benzodiazepines are prescribed on a short-term basis. Further study of benzodiazepines in the treatment of acute chest pain is needed to confirm these favorable actions and better define their use in the acute medical setting.
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Affiliation(s)
- Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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22
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Abstract
Treatment of spastic motility disorders continues to be challenging. Therapeutic options remain limited due in part to our lack of understanding of the pathophysiology and significance of these disorders. Furthermore, most of therapeutic trials to date are hampered by the poorly designed nature of the study, including the small size of the trials and the lack of placebo arm. Most of the available information suggests that there seems to be an important dissociation between symptoms (chest pain/dysphagia) and esophageal dysmotility. Drug treatment aimed at visceral sensitivity seems more effective in relieving symptoms than spasmolytic medications. Recent trials with Botox, nitric oxide derivatives, and SSRIs offer promising results. Rigorous study design that includes large placebo-controlled trials is needed in this area.
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Affiliation(s)
- Sami R Achem
- Department of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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23
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Abstract
BACKGROUND Achalasia is a disease that impairs oesophageal motility. Though nitrates have been used to treat achalasia for a long time, the effectiveness of nitrates for achalasia is still controversial. OBJECTIVES To quantify short-term and long-term effects of nitrate therapy in patients with achalasia. SEARCH STRATEGY Trials were identified by searching the Cochrane Controlled Trials Register (Issue 4-2001), MEDLINE (1966-2001), EMBASE (1980-2001), LILACS - Latin American and Caribbean health science literature (1982-2001) and CBM-Chinese Biomedical database(1980-2000). Additionally, all references in the identified trials were checked for further relevant trials. An updated search was run on the Cochrane Library, MEDLINE, and EMBASE in September 2003 - no new trials were found. SELECTION CRITERIA All randomised controlled trials involving achalasic patients given any type of nitrates were included. DATA COLLECTION AND ANALYSIS Data were extracted by two independent observers based on the intention to treat principle. MAIN RESULTS Two randomised cross-over studies were found, but no results are included. Due to the design of the studies and the method of reporting the results in the original paper it was not possible to extract the necessary information to examine any of the outcomes. REVIEWER'S CONCLUSIONS We can conclude no implications for practice at this stage. Appropriately designed parallel group randomised controlled trials with long term follow-up are needed to determine the effects of nitrates.
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Affiliation(s)
- Zhonghui Wen
- West China Hospital, Sichuan UniversityDepartment of Digestive DiseaseNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Elizabeth Gardener
- University of CambridgeDepartment of Public Health and Primary CareInstitute of Public Health, Forvie SiteRobinson WayCambridgeUKCB2 2SR
| | - Yiping Wang
- West China Hospital, Sichuan UniversityDepartment of Digestive DiseaseNo. 37, Guo Xue XiangChengduSichuanChina610041
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24
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Abstract
Medication-induced oesophageal distress and injury have become increasingly common conditions. First, smooth muscle relaxants may worsen or produce symptoms of pre-existing gastro-oesophageal reflux disease; notable examples include certain calcium antagonists (nifedipine), nitrates, sildenafil, nicotine, theophylline, and substances with antimuscarinic potential. Second, drugs with local toxicity may produce de novo damage including inflammation, strictures, ulcers, and bleeding. Notorious examples are alendronate, certain antibiotics including tetracyclines and clindamycin, all NSAIDs/aspirin, quinidine, potassium chloride, and ferrous sulfate. Cyclooxygenase-2 inhibitors may be devoid of such toxicity, but may damage the mucosa by interfering with regenerative cell proliferation. The galenic formulation can modulate the risk of oesophageal injury. For this reason, medicines containing the same potentially toxic ingredient may be less exchangeable than commonly thought. Diagnostic gold standard is endoscopy. The best treatment is removal of the offending drug and supportive care. Prevention requires a re-appraisal of the drug's indication and adherence to guidelines of optimal drug intake including ingestion in an upright position and swallowing with enough fluid. The clinical relevance of drug-induced oesophageal injury and the feasibility of therapeutic alternatives are individually addressed.
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Affiliation(s)
- Karl-Uwe Petersen
- Institut für Pharmakologie und Toxikologie, Rheinisch-Westfälische Technische Hochschule Aachen, Wendlingweg 2, 52057 Germany.
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25
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Gaudric M, Chaussade S. [Digestive tract and botulinum toxin]. ANNALES DE READAPTATION ET DE MEDECINE PHYSIQUE : REVUE SCIENTIFIQUE DE LA SOCIETE FRANCAISE DE REEDUCATION FONCTIONNELLE DE READAPTATION ET DE MEDECINE PHYSIQUE 2003; 46:353-60. [PMID: 12928143 DOI: 10.1016/s0168-6054(03)00128-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION the aim of this work was to check literature to assess botulinum toxin injection efficacy in gastrointestinal motor disorders with special emphasis on controlled clinical trials. METHODS literature was carried out with the Medline data bank. RESULTS seventy three articles in French and in English including a recent general review were retained. Comparative clinical trials only concerned achalasia and anal fissure. The other gastrointestinal motor disorders only gave rise to open non-controlled trials assessed on clinical end points. DISCUSSION this review of literature helps to determine usefulness and safety of Botulinum toxin injection in the treatment of esophageal achalasia and anal fissure. The main limitation is its brief duration of action. Studies concerning the others spastic motor disorders are based on unknown physiopathology and controlled trials are required to assess its efficacy. CONCLUSION botulinum toxin is increasingly used for gastrointestinal motor disorders with worthwhile results. Its efficacy has been yet established for only two disorders : it has a valuable palliative role in achalasia and may be curative for anal fissure.
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Affiliation(s)
- M Gaudric
- Service d'hépatogastroentérologie, hôpital Cochin, 27, rue du faubourg-Saint-Jacques, 75014 Paris, France.
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26
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Abstract
Noncardiac chest pain is a heterogeneous condition for which diagnosis and treatment are challenging. Research is needed to streamline evaluation to minimize unnecessary invasive testing and costs. Chest pain clinics to assess chest pain patients are popular in the United States and may be of value in reassuring patients and reducing presentation to hospital; however, recently this has been contended [111]. Options for the effective treatment of NCCP are dependent on the risk of an adverse outcome and the cost-effectiveness of the management algorithm that is followed. Most (64%) of those presenting to the emergency department with chest pain are classified as having NCCP [112,113]. GERD is probably the most important cause and application of a test of acid suppression with a high-dose PPI for 1 to 2 weeks seems to be a useful diagnostic tool. In those patients with GERD-related NCCP, short-term and potentially long-term therapy with a PPI (commonly higher than standard dose) is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon in patients with NCCP and evaluation by esophageal manometry might be limited to rule out achalasia. Chest wall syndromes are common but probably often missed. Many patients with NCCP have psychologic or psychiatric abnormalities, as either the cause or an effect of the chest pain, but diagnosis here depends on techniques not applied easily in the acute situation. Pain modulators seem to offer significant improvement in chest pain symptoms for non-GERD-related NCCP. Finally, trials of management strategies to deal with this problem are required urgently, because the earlier discharge of patients with NCCP may exacerbate the problem. Fig. 2 provides a flow chart for diagnosis and treatment of NCCP.
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Affiliation(s)
- Guy D Eslick
- Department of Medicine, University of Sydney, Nepean Hospital, Level 5, South Block, PO Box 63, Penrith, New South Wales 2751, Australia
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27
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Abstract
BACKGROUND Achalasia is a disease that impairs oesophageal motility. Though nitrates have been used to treat achalasia for a long time, the effectiveness of nitrates for achalasia is still controversial. OBJECTIVES To quantify short-term and long-term effects of nitrate therapy in patients with achalasia. SEARCH STRATEGY Trials were identified by searching the Cochrane Controlled Trials Register (Issue 4-2001), MEDLINE (1966-2001), EMBASE (1980-2001), LILACS - Latin American and Caribbean health science literature (1982-2001) and CBM-Chinese Biomedical database(1980-2000). Additionally, all references in the identified trials were checked for further relevant trials. SELECTION CRITERIA All randomised controlled trials involving achalasic patients given any type of nitrates were included. DATA COLLECTION AND ANALYSIS Data were extracted by two independent observers based on the intention to treat principle. MAIN RESULTS Two randomised cross-over studies were found, but no results are included. Due to the design of the studies and the method of reporting the results in the original paper it was not possible to extract the necessary information to examine any of the outcomes. REVIEWER'S CONCLUSIONS We can conclude no implications for practice at this stage. Appropriately designed parallel group randomised controlled trials with long term follow-up are needed to determine the effects of nitrates.
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Affiliation(s)
- Z H Wen
- Department of Gastroenterology, West China Hospital of Sichuan University, Guo Xue Xiang 37#, Chengdu, China, 610041.
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28
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Abstract
GOALS Review of research directions in the etiology, evaluation, and treatment of patients with noncardiac chest pain. The author proposes a combined practical approach to noncardiac chest pain that incorporates these findings, which is useful in a clinical practice setting. BACKGROUND Several major schools of thought have emerged in the etiology of noncardiac chest pain: acid reflux, motor disorder, altered pain threshold/hypersensitivity, and association with psychiatric dysfunction. There is significant overlap among these. Occult gastroesophageal reflux disease (GERD) is more common than motor disorders and is found in 30% to 40% of these patients; a subset has hypersensitivity, with a normal pH profile. Esophageal motility testing and endoscopy have a more limited role than 24-hour pH testing. Impedance planimetry and balloon sensory provocative testing remain research tools. Provocative testing with hydrochloric acid or edrophonium is less helpful than pH monitoring. Gastroesophageal reflux disease-induced chest pain requires high-dose long-term proton pump inhibitors (PPIs): at least 4 to 8 weeks. Psychotropics are superior to placebo, both in patients with and without psychiatric dysfunction. RESULTS The author found combined PPIs and psychotropics helpful in patients with esophageal hypersensitivity and GERD, although supporting data is scant. CONCLUSIONS A brief 1-week high-dose PPI challenge, i.e., omeprazole test, may be cost-effective in a primary care setting. However, this approach may not be useful in a referral setting, where pH data and diary assessment of associated symptoms provide useful management help. A behavioral model approach, with early emphasis on patient education, integrated with physiologic data helps the most.
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Affiliation(s)
- V Alin Botoman
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida 33331, USA.
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29
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Storr M, Allescher HD, Rösch T, Born P, Weigert N, Classen M. Treatment of symptomatic diffuse esophageal spasm by endoscopic injections of botulinum toxin: a prospective study with long-term follow-up. Gastrointest Endosc 2001. [PMID: 11726856 DOI: 10.1067/mge.2001.119256] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diffuse esophageal spasm is a rare esophageal motility disorder for which there are no satisfactory pharmacologic alternatives for treatment. The aim of this study was to investigate whether botulinum toxin (BTX) injection is an effective short- and long-term treatment for patients with symptoms caused by diffuse esophageal spasm. Whether recurrence of clinical symptoms can be successfully retreated by BTX injection was also studied. METHODS Nine symptomatic patients (6 women, 3 men; 57-86 years) with manometrically proven diffuse esophageal spasm underwent BTX injection. One hundred IU BTX were diluted in l0 mL of saline solution and injected endoscopically at multiple sites along the esophageal wall beginning in the region of the lower esophageal sphincter and moving proximally in 1- to 1.5-cm intervals, and into endoscopically visible contraction rings. Symptom scores based on an analogue scale for dysphagia, regurgitation, and noncardiac chest pain were assessed before and after therapy, 1 day thereafter, and at 1 and 6 months. RESULTS Symptoms improved immediately in 7 (78%) patients after 1 injection session. After 4 weeks 8 (89%) patients were in remission with a decrease in total symptom score. The total symptom score decreased from a median 8.0 (interquartile range: 6.75; 9.0) before treatment to 2.0 (1.5; 3.75) after 1 day (p < 0.01) and to 2.0 (interquartile range: 0.75; 3.0) after 1 month (p < 0.01). After 6 months all 8 patients with a response at 1 month still had a symptom score of 3 or less without further treatment. Subsequently 4 patients required reinjection 8, 12, 15, or 24 months after the initial treatment with similarly good results. No serious adverse effects were observed. CONCLUSIONS BTX injection at several levels of the tubular esophagus is an effective treatment for patients with symptoms caused by diffuse esophageal spasm. Symptom relapse can be effectively treated by repeated BTX injection.
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Affiliation(s)
- M Storr
- Department of Internal Medicine II, Technical University of Munich, Germany
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30
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Storr M, Allescher HD, Classen M. Current concepts on pathophysiology, diagnosis and treatment of diffuse oesophageal spasm. Drugs 2001; 61:579-91. [PMID: 11368284 DOI: 10.2165/00003495-200161050-00004] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Diffuse oesophageal spasm is a functional oesophageal motility disorder of unknown aetiology, which appears to be due to a disturbance of the normal pharmacological timing of propulsive contraction occurring in the oesophageal body after swallowing. The lack of pathophysiological understanding may be due to the fact that there is more than one pathophysiological pathway causing symptoms of diffuse oesophageal spasm. Barium studies, oesophageal scintigraphy and fiberoptic examination can be helpful in finding the correct diagnosis, but manometry is still the gold standard of diagnostic procedures. Similar to other spastic oesophageal motility disorders, pharmacological treatment of diffuse oesophageal spasm includes nitrates, calcium antagonists, anticholinergics and antidepressants with varying beneficial effects. Botulinum toxin, which provides sufficient treatment as measured by symptom score and manometric patterns in patients with achalasia, was recently evaluated for the treatment of diffuse oesophageal spasm in small patient selections with promising results.
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Affiliation(s)
- M Storr
- Department of Internal Medicine II, Technical University of Munich, Germany.
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31
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Storr M, Meining A, Allescher HD. Pharmacoeconomic issues of the treatment of gastroesophageal reflux disease. Expert Opin Pharmacother 2001; 2:1099-108. [PMID: 11583061 DOI: 10.1517/14656566.2.7.1099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common diagnoses in a gastroenterologist's practice. Gastroesophageal reflux (GER) describes the retrograde movement of gastric contents through the lower oesophageal sphincter (LES) to the oesophagus. GER can occur physiologically and may be accompanied by symptoms. The introduction of endoscopes and ambulatory devices for continuous monitoring of oesophageal pH (24 h pH monitoring) has led to great improvement in the ability to diagnose reflux disease and reflux-associated complications. The development of pathological reflux and GERD can be attributed to many factors. Pathophysiology of GERD includes transient lower oesophageal sphincter relaxations (TLESRs), incompetent LES because of a decreased lower oesophageal sphincter pressure (LESP) and deficient or delayed oesophageal acid clearance. Uncomplicated GERD may be treated by modification of lifestyle and eating habits in an early stage of GERD. The various agents currently used for treatment of GERD include mucoprotective substances, antacids, H2-blockers, prokinetics and proton pump inhibitors (PPIs). Although these drugs are effective, they do not necessarily influence the underlying causes of the disease by improving the oesophageal clearance, increasing the LESP or reducing the frequency of TLESRs. The following article gives an overview regarding current concepts of the pathophysiology and pharmacological treatment of GERD stressing on pharmacoeconomic issues of the treatment and discusses the advantages and disadvantages for step-up and step-down therapy.
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Affiliation(s)
- M Storr
- Department of Internal Medicine II, Technical University of Munich, Germany.
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32
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Arora AS, Conklin JL. Practical approaches to dysphagia caused by Esophageal motor disorders. Curr Gastroenterol Rep 2001; 3:191-9. [PMID: 11353554 DOI: 10.1007/s11894-001-0021-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Dysphagia is a common symptom with which patients present. This review focuses primarily on the esophageal motor disorders that result in dysphagia. Following a brief description of the normal swallowing mechanisms and the messengers involved, more specific motor abnormalities are discussed. The importance of achalasia, as the only pathophysiologically defined esophageal motor disorder, is discussed in some detail, including recent developments in pathogenesis and treatment options. Other esophageal spastic disorders are described, with relevant manometric tracings included. In recent years, the importance of gastroesophageal reflux as a primary cause of esophageal dysmotility has been recognized, and this is also discussed. In addition, the motility disturbances that develop after surgical fundoplication are reviewed.
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Affiliation(s)
- A S Arora
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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