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Vázquez-Elizondo G, Remes-Troche JM, Valdovinos-Díaz MÁ, Coss-Adame E, Morán ES, Achem SR. Diagnostic differences in high-resolution esophageal motility in a large Mexican cohort based on geographic distribution. Dis Esophagus 2024; 37:doae049. [PMID: 38857460 DOI: 10.1093/dote/doae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/04/2024] [Accepted: 05/26/2024] [Indexed: 06/12/2024]
Abstract
High-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016-2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences.
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Affiliation(s)
- Genaro Vázquez-Elizondo
- Gastroenterology Department, Centro de Enfermedades Digestivas ONCARE, Monterrrey, Nuevo León, Mexico
| | - José María Remes-Troche
- Gastroenterology Department, Laboratorio de Motilidad Gastrointestinal y Fisiología Digestiva, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, México
| | | | - Sami R Achem
- Gastroenterology Department, Mayo College of Medicine, Mayo Clinic, Florida, USA
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Goyal RK, Rattan S. Role of mechanoregulation in mast cell-mediated immune inflammation of the smooth muscle in the pathophysiology of esophageal motility disorders. Am J Physiol Gastrointest Liver Physiol 2024; 326:G398-G410. [PMID: 38290993 PMCID: PMC11213482 DOI: 10.1152/ajpgi.00258.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 02/01/2024]
Abstract
Major esophageal disorders involve obstructive transport of bolus to the stomach, causing symptoms of dysphagia and impaired clearing of the refluxed gastric contents. These may occur due to mechanical constriction of the esophageal lumen or loss of relaxation associated with deglutitive inhibition, as in achalasia-like disorders. Recently, immune inflammation has been identified as an important cause of esophageal strictures and the loss of inhibitory neurotransmission. These disorders are also associated with smooth muscle hypertrophy and hypercontractility, whose cause is unknown. This review investigated immune inflammation in the causation of smooth muscle changes in obstructive esophageal bolus transport. Findings suggest that smooth muscle hypertrophy occurs above the obstruction and is due to mechanical stress on the smooth muscles. The mechanostressed smooth muscles release cytokines and other molecules that may recruit and microlocalize mast cells to smooth muscle bundles, so that their products may have a close bidirectional effect on each other. Acting in a paracrine fashion, the inflammatory cytokines induce genetic and epigenetic changes in the smooth muscles, leading to smooth muscle hypercontractility, hypertrophy, and impaired relaxation. These changes may worsen difficulty in the esophageal transport. Immune processes differ in the first phase of obstructive bolus transport, and the second phase of muscle hypertrophy and hypercontractility. Moreover, changes in the type of mechanical stress may change immune response and effect on smooth muscles. Understanding immune signaling in causes of obstructive bolus transport, type of mechanical stress, and associated smooth muscle changes may help pathophysiology-based prevention and targeted treatment of esophageal motility disorders.NEW & NOTEWORTHY Esophageal disorders such as esophageal stricture or achalasia, and diffuse esophageal spasm are associated with smooth muscle hypertrophy and hypercontractility, above the obstruction, yet the cause of such changes is unknown. This review suggests that smooth muscle obstructive disorders may cause mechanical stress on smooth muscle, which then secretes chemicals that recruit, microlocalize, and activate mast cells to initiate immune inflammation, producing functional and structural changes in smooth muscles. Understanding the immune signaling in these changes may help pathophysiology-based prevention and targeted treatment of esophageal motility disorders.
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Affiliation(s)
- Raj K Goyal
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, United States
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, United States
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Sidney Kummel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Wang Y, Yu T, Zhu F, Xu Y, Bao Y, Zhang L, Lin L, Tang Y. Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data. Diagnostics (Basel) 2023; 13:2329. [PMID: 37510073 PMCID: PMC10378678 DOI: 10.3390/diagnostics13142329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up. METHODS Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment. RESULTS The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications. CONCLUSIONS Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.
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Affiliation(s)
- Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ting Yu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Feng Zhu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ying Xu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yun Bao
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology and Hepatology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 440307, China
| | - Ling Zhang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology, Southeast University Zhongda Hospital, Nanjing 210029, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yurong Tang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
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Canakis A, Xie G, Kim RE. Peroral Endoscopic Myotomy Is an Effective Treatment Option for Managing Jackhammer Esophagus: A Single Center Experience. J Clin Gastroenterol 2023; 57:569-573. [PMID: 35537134 DOI: 10.1097/mcg.0000000000001717] [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: 01/17/2022] [Accepted: 03/26/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Jackhammer esophagus (JE) is a rare hypercontractile motility disorder often associated with dysphagia, regurgitation, and chest pain. In patients with clinically relevant symptoms, treatment options aim to decrease esophageal contractions. Medical, endoscopic and surgical therapies have limited long-term efficacy. The advent of peroral endoscopic myotomy (POEM) has evolved as a minimally invasive treatment option. Yet data regarding JE is scare. As such we aimed to investigate the clinical efficacy of JE. PATIENTS AND METHODS This was a single center retrospective study of consecutive adult patients undergoing POEM for JE from April 2018 to September 2021. All procedures were conducted by a single endoscopist. Primary outcome was clinical success, defined as Eckardt score (ES) ≤3 following the procedure. RESULTS A total of 13 patients (mean age 58, 7 females) underwent POEM with a mean duration of symptoms of 42.6 months. Preprocedure mean ES was 8.92. Nine patients were treatment naive. Pre-POEM endoluminal functional luminal imaging probe (n=10) demonstrated a distensibility index of 0.34. The average length of follow-up after POEM was 15.8 months.There was a 92.3% (12/13) clinical success rate, with a mean post-POEM ES of 1.53. One patient's ES improved from 12 to 1 after POEM; however, 2.5 years later she developed recurrent symptoms (ES 10). Only 1 patient had endoscopic evidence of Los Angeles grade A esophagitis. One year after POEM, 5 patients had gastroesophageal reflux disease symptoms, but only 2 required acid suppression therapy. CONCLUSION POEM is an effective treatment modality with long-term efficacy. Larger, prospective studies are needed to validate these findings.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, University of Maryland Medical Center
| | - Guofeng Xie
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, University of Maryland Medical Center
- Veterans Affairs Maryland Health Care System, Baltimore, MD
| | - Raymond E Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, University of Maryland Medical Center
- Veterans Affairs Maryland Health Care System, Baltimore, MD
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Manometric evaluation of dysphagia. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Jadcherla AV, Litzenberg K, Balasubramanian G. Esophageal Dysfunction in Post-lung Transplant: An Enigma. Dysphagia 2022; 38:731-743. [PMID: 35960395 DOI: 10.1007/s00455-022-10508-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.
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Affiliation(s)
| | - Kevin Litzenberg
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, Gastrointestinal Motility Laboratory, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd Floor, Columbus, OH, USA.
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Sharma P, Yadlapati R. Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0. Curr Gastroenterol Rep 2022; 24:10-17. [PMID: 35084643 PMCID: PMC9380285 DOI: 10.1007/s11894-022-00836-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
PURPOSE OF REVIEW Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classification version 4.0 (CCv4.0), which aimed to enhance diagnostic characterization and limit overdiagnosis of inconclusive esophageal motility diagnoses. RECENT FINDINGS Key revisions outlined in CCv4.0 include (1) a modified standardized HRM study protocol performed in supine and upright positions, (2) recommended ancillary testing and manometric provocation for inconclusive manometric diagnoses (3) the required presence of obstructive symptoms for conclusive diagnoses of esophagogastric junction outflow obstruction, distal esophageal spasm and hypercontractile esophagus, and (4) requirement of confirmatory testing for esophagogastric junction outflow obstruction. These key modifications aim to improve diagnostic accuracy and consistency of clinically relevant esophageal motility disorders, and subsequently clinical outcomes.
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Affiliation(s)
- Priya Sharma
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, ACTRI, Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA, 92093, USA.
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