Esophageal motor disorders

Idiopathic (primary) achalasia: a review

Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.

Idiopathic (primary) achalasia

Idiopathic achalasia is a primary esophageal motor disorder characterized by esophageal aperistalsis and abnormal lower esophageal sphincter (LES) relaxation in response to deglutition. It is a rare disease with an annual incidence of approximately 1/100,000 and a prevalence rate of 1/10,000. The disease can occur at any age, with a similar rate in men and women, but is usually diagnosed between 25 and 60 years. It is characterized predominantly by dysphagia to solids and liquids, bland regurgitation, and chest pain. Weight loss (usually between 5 to 10 kg) is present in most but not in all patients. Heartburn occurs in 27%-42% of achalasia patients. Etiology is unknown. Some familial cases have been reported, but the rarity of familial occurrence does not support the hypothesis that genetic inheritance is a significant etiologic factor. Association of achalasia with viral infections and auto-antibodies against myenteric plexus has been reported, but the causal relationship remains unclear. The diagnosis is based on history of the disease, radiography (barium esophagogram), and esophageal motility testing (esophageal manometry). Endoscopic examination is important to rule out malignancy as the cause of achalasia. Treatment is strictly palliative. Current medical and surgical therapeutic options (pneumatic dilation, surgical myotomy, and pharmacologic agents) aimed at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Although it cannot be permanently cured, excellent palliation is available in over 90% of patients.

Metastatic bone cancer as a recurrence of early gastric cancer - characteristics and possible mechanisms

The surgical outcome of most early gastric cancer (EGC) is usually satisfactory. Some cases show bone metastasis even though the depth of cancer invasion is confined to the mucosa. The most frequent site for recurrence of EGC is the liver. Cases of EGC with bone metastasis are reviewed to clarify the clinicopathological characteristics of EGC giving rise to bone metastasis. Possible mechanisms and risk factors underlying this rare condition are proposed. Forty-six cases of bone metastasis from EGC are reviewed from published reports and meeting proceedings in Japan. This investigation suggests that risk factors for bone metastasis from EGC include depressed-type signet-ring cell carcinoma, poorly differentiated carcinoma, and/or the likely involvement of lymph node metastasis, even though the cancer is confined to the gastric mucosa. The risk factors do not include recurrence of EGC in the liver. We speculate that the mechanism of bone metastasis from EGC is via lymphatic channels and systemic circulation. Post-operative follow-up of cases should consider the development of bone metastasis from EGC. We propose the use of elevated alkaline phosphatase levels for the detection of bone metastasis and recommend bone scintigraphy in positive cases.

Long-term results of pneumatic dilation for achalasia: A 15 years’ experience

AIM: Although most patients with achalasia respond to pneumatic dilation, one-third experienced recurrence, and prolonged follow-up studies on parameters associated with various outcomes are scanty. In this retrospective study, we reported a 15-years’ experience with pneumatic dilation treatment in patients with primary achalasia, and determined whether previously described predictors of outcome remain significant after endoscopic dilation.

METHODS: Between September 1989 and September 2004, 39 consecutive patients with primary symptomatic achalasia (diagnosed by clinical presentation, esophagoscopy, barium esophagogram, and manometry) who received balloon dilation were followed up at regular intervals in person or by phone interview. Remission was assessed by a structured interview and a previous symptoms score. The median dysphagia-free duration was calculated by Kaplan-Meier analysis.

RESULTS: Symptoms were dysphagia (n = 39, 100%), regurgitation (n = 23, 58.7%), chest pain (n = 4, 10.2%), and weight loss (n = 26, 66.6%). A total of 74 dilations were performed in 39 patients; 13 patients (28%) underwent a single dilation, 17 patients (48.7%) required a second procedure within a median of 26.7 mo (range 5-97 mo), and 9 patients (23.3%) underwent a third procedure within a median of 47.8 mo (range 37-120 mo). Post-dilation lower esophageal sphincter (LES) pressure, assessed in 35 patients, has decreased from a baseline of 35.8 ± 10.4-10.0 ± 7.1 mmHg after the procedure. The median follow-up period was 9.3 years (range 0.5-15 years). The dysphagia-free duration by Kaplan-Meier analysis was 78%, 61% and 58.3% after 5, 10 and 15 years respectively.

CONCLUSION: Balloon dilation is a safe and effective treatment for primary achalasia. Post-dilation LES pressure estimation may be useful in assessing response.

Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia

AIM: Achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES) has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation remains the first choice of treatment. The aims of this study were to determine the long term clinical outcome of treating achalasia initially with pneumatic dilatation and usefulness of pneumatic dilatation technique under endoscopic observation without fluoroscopy.

METHODS: A total of 65 dilatations were performed in 43 patients with achalasia [23 males and 20 females, the mean age was 43 years (range, 19-73)]. All patients underwent an initial dilatation by inflating a 30 mm balloon to 15 psi under endoscopic control. The need for subsequent dilatation was based on symptom assessment. A 3.5 cm balloon was used for repeat procedures.

RESULTS: The 30 mm balloon achieved a satisfactory result in 24 patients (54%) and the 35 mm ballon in 78% of the remainder (14/18). Esophageal perforation as a short-term complication was observed in one patient (2.3%). The only late complication encountered was gastroesophageal reflux in 2 (4%) patients with a good response to dilatation. The mean follow-up period was 2.4 years (6 mo - 5 years). Of the patients studied, 38 (88%) were relieved of their symptoms after only one or two sessions. Five patients were referred for surgery (one for esophageal perforation and four for persistent or recurrent symptoms). Among the patients whose follow up information was available, the percentage of patients in remission was 79% (19/24) at 1 year and 54% (7/13) at 5 years.

CONCLUSION: Performing balloon dilatation under endoscopic observation as an outpatient procedure is simple, safe and efficacious for treating patients with achalasia and referral of surgical myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilatations.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.