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Low EE, Fehmi SA, Hasan A, Chang M, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Carlson DA, Pandolfino JE, Yadlapati R. Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group. Neurogastroenterol Motil 2022; 34:e14449. [PMID: 35972282 PMCID: PMC9722506 DOI: 10.1111/nmo.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. METHODS This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. KEY RESULTS Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). CONCLUSIONS AND INFERENCES We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Michael Chang
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics & Informatics, University of Colorado, Denver, Colorado, USA
| | - Dustin A. Carlson
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Zifan A, Gandu V, Mittal RK. Esophageal wall compliance/stiffness during peristalsis in patients with functional dysphagia and high-amplitude esophageal contractions. Am J Physiol Gastrointest Liver Physiol 2022; 323:G586-G593. [PMID: 36283085 PMCID: PMC9678403 DOI: 10.1152/ajpgi.00075.2022] [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: 03/25/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023]
Abstract
Recent studies that utilized distension/contraction plots to study peristalsis reveal poor distension of the esophagus in patients with functional dysphagia and high-amplitude contractions [high-amplitude esophageal contractions (HAECs)] even though the contraction phase of peristalsis is normal in these patients. Our goal was to determine biomechanical properties of the esophageal wall and bolus flow characteristics in patients with functional dysphagia and HAEC during primary peristalsis. Studies were performed on 30 healthy subjects, 30 patients with functional dysphagia, and 25 patients with HAEC. Subjects swallowed 10 mL, 0.5 N saline bolus in the Trendelenburg position to study primary peristalsis. A custom-built software (Dplots) determined peak distension from the impedance measurements, pressure at peak distension, wall tension (pressure × radius), wall distensibility [cross-sectional area (CSA)/pressure], and bolus flow (cm3/s) in four segments of esophagus (between upper and lower esophageal sphincter). Luminal CSA of distal esophagus was smaller, and average bolus flow rate was faster in patients with functional dysphagia and HAEC. Esophageal wall distensibility, a measure of esophageal wall compliance was lower and wall tension was higher in the distal esophagus of both patient groups compared with normal subjects. Ultrasound imaging confirmed poor distension of the esophagus. A trend toward greater wall thickness at the peak of distension was found in patients with functional dysphagia compared with normal subjects. A stiffer or noncompliant esophageal wall is the reason for poor distension of the esophagus during primary peristalsis in patients with functional dysphagia and HAEC.NEW & NOTEWORTHY We studied healthy asymptomatic subject, patients with functional dysphagia (FD), and patients with high-amplitude esophageal contractions (HAEC). Our data show that in patients with HAEC and functional dysphagia, luminal distension is smaller (low luminal CSA at peak distension), intraluminal pressure is higher, and liquid bolus travels faster through the esophagus as compared with normal subjects. We conclude that patients with functional dysphagia and HAEC have a stiffer distal esophageal wall during bolus transport related to primary peristalsis.
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Affiliation(s)
- Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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Per-oral endoscopic myotomy and gastroesophageal reflux: Where do we stand after a decade of "POETRY"? Indian J Gastroenterol 2019; 38:287-294. [PMID: 31478146 DOI: 10.1007/s12664-019-00980-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/18/2019] [Indexed: 02/04/2023]
Abstract
Per-oral endoscopic myotomy (POEM) was introduced nearly a decade ago. Since then, the literature on its safety and efficacy has been ever increasing. Initial studies focused solely on the feasibility and efficacy of this procedure in patients with idiopathic achalasia. Subsequent studies analyzed the incidence of gastroesophageal reflux disease (GERD) in addition to the efficacy of POEM. These studies depict a high incidence of GERD after POEM. However, vast majority of these studies lacked a comprehensive evaluation of GERD after POEM. Consequently, it is difficult to provide a true estimate of the incidence of GERD in these patients. Majority of the patients with post-POEM GERD are asymptomatic and those with symptoms usually respond well to proton pump inhibitors. However, the long-term consequences of asymptomatic GERD with increased esophageal acid exposure are not well known. These patients should probably undergo regular surveillance due to theoretical risks of complications like Barrett's esophagus and esophageal adenocarcinoma. It should be acknowledged that there is no well-controlled study to support the strategy of surveillance in this group of patients. Given the high incidence of GERD after POEM, it is time to devise minimally invasive novel strategies to prevent and manage post-POEM GERD. The current literature suggests that the technique of POEM and other factors like type of achalasia do not influence the occurrence of GERD after POEM. Therefore, the endoscopists will need to think out of the box to prevent post-POEM GERD.
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Biasutto D, Roman S, Garros A, Mion F. Esophageal shortening after rapid drink test during esophageal high-resolution manometry: A relevant finding? United European Gastroenterol J 2018; 6:1323-1330. [PMID: 30386605 DOI: 10.1177/2050640618796752] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background Esophageal shortening (ES) might be observed during high-resolution manometry (HRM), in particular after the rapid drink test (RDT). We aimed to assess its diagnostic value in patients referred for HRM. Methods HRM of patients without previous esophagogastric surgery or endoscopic treatment was retrospectively reviewed using the Chicago Classification v3.0. ES and pan-esophageal pressurization were analyzed during the RDT (200-ml free drinking in a sitting position). Results A total of 2141 cases (1291 females, mean age 54 years) were reviewed. During the RDT, ES occurred in 4% and pan-esophageal pressurization in 14% of patients. ES was almost exclusively encountered in patients with impaired esophagogastric junction relaxation or major disorders of peristalsis. Among 31 patients with ES and no definite diagnosis of achalasia, 19 had follow-up and 13 (68%) changed diagnostic category: two adenocarcinoma of the cardia, and 11 cases of atypical achalasia. The positive predictive value of ES for a significant esophageal disorder was 95%. Conclusion ES is rarely observed during the RDT. When present, it is associated with major motility disorders, especially achalasia. When the diagnostic criteria for achalasia are not fulfilled, further complementary examinations should be performed to rule out incomplete forms of achalasia or an infiltrative process of the cardia.
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Affiliation(s)
| | - Sabine Roman
- Digestive Physiology, Université de Lyon, France.,Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France.,Inserm U1032, LabTAU, Université de Lyon, France
| | - Aurelien Garros
- Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France
| | - Francois Mion
- Digestive Physiology, Université de Lyon, France.,Digestive Physiology, Hôpital E Herriot, Hospices Civils de Lyon, France.,Inserm U1032, LabTAU, Université de Lyon, France
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Chihara D, Romer AI, Bentzinger CF, Rudnicki MA, Krauss RS. PAX7 is required for patterning the esophageal musculature. Skelet Muscle 2015; 5:39. [PMID: 26635949 PMCID: PMC4668666 DOI: 10.1186/s13395-015-0068-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/07/2015] [Indexed: 12/12/2022] Open
Abstract
Background The mammalian esophageal musculature is unique in that it makes a transition from smooth to skeletal muscle, with most of this process occurring after birth. In order to better understand the mechanisms that control esophageal musculature development, we investigated the roles in this process of the paired box transcription factor, PAX7, a principal regulator of skeletal myogenic progenitor cells. Previous studies showed that Pax7 is important for determining the esophageal muscle composition. Results We characterized the postnatal development of the esophageal musculature in Pax7−/− mice by analyzing morphology, muscle composition, and the expression of markers of myogenesis, cell proliferation, and apoptosis. Pax7−/− mice displayed megaesophagus with a severe defect in the postnatal developmental process whereby esophageal smooth muscle is replaced by skeletal muscle. Pax7−/− esophagi have substantially reduced skeletal muscle, most likely due to diminished proliferation and premature differentiation of skeletal muscle precursor cells. This impaired the proximal-to-distal progression of skeletal myogenesis and indirectly affected the patterning of the smooth muscle-containing portion of the esophageal musculature. Conclusions Postnatal patterning of the esophageal musculature appears to require robust, PAX7-dependent cell proliferation to drive the proximal-to-distal progression of skeletal myogenesis. This process in turn influences distal smooth muscle morphogenesis and development of the mature pattern of the esophageal musculature. Electronic supplementary material The online version of this article (doi:10.1186/s13395-015-0068-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daisuke Chihara
- Department of Developmental and Regenerative Biology, Mount Sinai School of Medicine, New York, NY 10029 USA
| | - Anthony I Romer
- Department of Developmental and Regenerative Biology, Mount Sinai School of Medicine, New York, NY 10029 USA ; Graduate School of Biological Sciences, One Gustave L. Levy Place, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA ; Present address: Department of Genetics and Development, Columbia University, 701 West 168th Street, HHSC 1602, New York, NY 10032 USA
| | - C Florian Bentzinger
- Regenerative Medicine Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, K1H 8L6 ON Canada ; Department of Cellular and Molecular Medicine, University of Ottawa, 451 Smyth Road, Ottawa, K1H 8M5 ON Canada ; Present address: Nestlé Institute of Health Sciences, EPFL Campus, 1015 Lausanne, Switzerland
| | - Michael A Rudnicki
- Regenerative Medicine Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, K1H 8L6 ON Canada ; Department of Cellular and Molecular Medicine, University of Ottawa, 451 Smyth Road, Ottawa, K1H 8M5 ON Canada
| | - Robert S Krauss
- Department of Developmental and Regenerative Biology, Mount Sinai School of Medicine, New York, NY 10029 USA ; Graduate School of Biological Sciences, One Gustave L. Levy Place, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
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Kou W, Pandolfino JE, Kahrilas PJ, Patankar NA. Simulation studies of circular muscle contraction, longitudinal muscle shortening, and their coordination in esophageal transport. Am J Physiol Gastrointest Liver Physiol 2015; 309:G238-47. [PMID: 26113296 PMCID: PMC4537927 DOI: 10.1152/ajpgi.00058.2015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/17/2015] [Indexed: 01/31/2023]
Abstract
On the basis of a fully coupled active musculomechanical model for esophageal transport, we aimed to find the roles of circular muscle (CM) contraction and longitudinal muscle (LM) shortening in esophageal transport, and the influence of their coordination. Two groups of studies were conducted using a computational model. In the first group, bolus transport with only CM contraction, only LM shortening, or both was simulated. Overall features and detailed information on pressure and the cross-sectional area (CSA) of mucosal and the two muscle layers were analyzed. In the second group, bolus transport with varying delay in CM contraction or LM shortening was simulated. The effect of delay on esophageal transport was studied. For cases showing abnormal transport, pressure and CSA were further analyzed. CM contraction by itself was sufficient to transport bolus, but LM shortening by itself was not. CM contraction decreased the CSA and the radius of the muscle layer locally, but LM shortening increased the CSA. Synchronized CM contraction and LM shortening led to overlapping of muscle CSA and pressure peaks. Advancing LM shortening adversely influenced bolus transport, whereas lagging LM shortening was irrelevant to bolus transport. In conclusion, CM contraction generates high squeezing pressure, which plays a primary role in esophageal transport. LM shortening increases muscle CSA, which helps to strengthen CM contraction. Advancing LM shortening decreases esophageal distensibility in the bolus region. Lagging LM shortening no longer helps esophageal transport. Synchronized CM contraction and LM shortening seems to be most effective for esophageal transport.
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Affiliation(s)
- Wenjun Kou
- 1Program of Theoretical and Applied Mechanics, Northwestern University, Evanston, Illinois;
| | - John E. Pandolfino
- 2Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
| | - Peter J. Kahrilas
- 2Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
| | - Neelesh A. Patankar
- 3Department of Mechanical Engineering, Northwestern University, Evanston, Illinois
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Boeckxstaens G, El-Serag HB, Smout AJPM, Kahrilas PJ. Republished: symptomatic reflux disease: the present, the past and the future. Postgrad Med J 2015; 91:46-54. [PMID: 25583739 PMCID: PMC4316838 DOI: 10.1136/postgradmedj-2013-306393rep] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.
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Affiliation(s)
- Guy Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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