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Pesce M, Pagliaro M, Sarnelli G, Sweis R. Modern Achalasia: Diagnosis, Classification, and Treatment. J Neurogastroenterol Motil 2023; 29:419-427. [PMID: 37814432 PMCID: PMC10577462 DOI: 10.5056/jnm23125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. As a consequence of the esophageal outflow obstruction, achalasia patients present with clinical symptoms of dysphagia, chest pain, weight loss, and regurgitation of indigested food. Other less specific symptoms can also present including heartburn, chronic cough, and aspiration pneumonia. The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. Other tools have also emerged to help define achalasia severity and which can be used as objective measures of response to therapy including the timed barium esophagogram and the functional lumen imaging probe. Such diagnostic innovations, along with the increased awareness by clinicians and patients due to the availability of alternative therapeutic approaches (laparoscopic and robotic Heller myotomy, and peroral endoscopic myotomy) have radically changed the natural history of the disorder. Herein, we report the most recent advances in the diagnosis, classification, and management of esophageal achalasia and underline the still-grey areas that needs to be addressed by future research to reach the goal of personalizing treatment.
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Affiliation(s)
- Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Marta Pagliaro
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Winston JM, Mann FAT, Dean L. Management and outcomes of 13 dogs treated with a modified Heller myotomy and Dor fundoplication for lower esophageal sphincter achalasia-like syndrome. Vet Surg 2023; 52:315-329. [PMID: 36458673 DOI: 10.1111/vsu.13912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To report the management and outcomes of dogs treated for lower esophageal sphincter achalasia-like syndrome (LES-AS) with modified Heller myotomy, Dor fundoplication, and with the use of a temporary gastrostomy tube. STUDY DESIGN Retrospective. SAMPLE POPULATION Thirteen client-owned dogs. METHODS Medical records and a client survey were used to assess frequency of vomiting/regurgitation, quality of life (QoL), bodyweight, and feeding modifications at the following time points: prior to referral, postoperatively from discharge to first recheck (4-6 weeks), and from first recheck to survey (48 months). Postoperative and gastrostomy tube complications were surveyed and recorded. Pretreatment and 4-6 weeks postoperative videofluoroscopic swallow studies (VFSS) were compared. Two-sided t-tests were used to compare outcomes between survey time points. RESULTS Postoperative VFSS scores (available in 9 dogs) improved over preoperative scores in 6 dogs, and 12/13 dogs survived to discharge. One dog was euthanized 3 days postoperatively due to aspiration pneumonia. Postoperative gastrostomy tube complications occurred in half of the dogs that survived to discharge. According to the owners, scores assigned to vomiting/regurgitation improved by 180% (P = .004), QoL by 100% (P = .004), and bodyweight by 63% (P = .035). CONCLUSION Modified Heller myotomy with Dor fundoplication and the use of a temporary gastrostomy tube improved clinical signs and owners' perceived quality of life in half of the dogs treated for LES-AS in our clinical setting. Oral sildenafil therapy discontinued postoperatively suggests that surgery was equally efficacious. CLINICAL SIGNIFICANCE Modified Heller myotomy with Dor fundoplication and temporary gastrostomy tube is a treatment option with potentially sustained benefits for dogs that have LES-AS.
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Affiliation(s)
- John M Winston
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - F A Tony Mann
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - Lauren Dean
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
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Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
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Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
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Gaber CE, Cotton CC, Eluri S, Lund JL, Farrell TM, Dellon ES. Autoimmune and viral risk factors are associated with achalasia: A case-control study. Neurogastroenterol Motil 2022; 34:e14312. [PMID: 34957646 PMCID: PMC9232907 DOI: 10.1111/nmo.14312] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Achalasia is a rare esophageal motility disorder of uncertain etiology. While past studies have indicated that autoimmune conditions and viral infections may be associated with development of achalasia, these associations are yet to be examined in large, population-based studies. METHODS A matched case-control study was performed using administrative claim data from the IBM MarketScan Commercial Claims and Encounters Database between 2000 and 2019. A history of selected autoimmune conditions and viral infections was assessed using past medical claims. Multivariable conditional logistic regression was used to account for the matched nature of the study design and further control for confounding by demographic and clinical characteristics when reporting adjusted odds ratios (aORs). KEY RESULTS Among 6769 cases and 27,076 controls, presence of any of the autoimmune conditions studied was associated with increased odds of achalasia (aOR = 1.26, 95% CI: 1.11, 1.42). Scleroderma or systemic sclerosis (aOR = 8.13, 95% CI: 3.34, 19.80) and Addison's disease (aOR = 3.83, 95% CI: 1.83, 8.04) had the strongest associations with achalasia. Presence of any of the viral infections studied was also associated with an increased risk of achalasia (aOR = 1.58, 95% CI: 1.23, 2.01). Varicella zoster virus (aOR = 3.84, 95% CI: 1.94, 7.62) and human papillomavirus (aOR = 1.77, 95% CI: 1.15, 2.73) both had strong relationships with achalasia. CONCLUSIONS AND INFERENCES These findings suggest that achalasia may have autoimmune and viral components contributing to its etiology. Future mechanistic studies could target specific diseases and agents highlighted by this research.
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Affiliation(s)
- Charles E. Gaber
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biologic and Diseases, Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biologic and Diseases, Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy M. Farrell
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biologic and Diseases, Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Tustumi F. Evaluating the Non-conventional Achalasia Treatment Modalities. Front Med (Lausanne) 2022; 9:941464. [PMID: 35814742 PMCID: PMC9263126 DOI: 10.3389/fmed.2022.941464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAchalasia is a primary esophageal dysmotility disorder. Despite the high volume of studies addressing the conventional treatments for achalasia, few are debated regarding the non-conventional treatments, such as cardiectomy, cardioplasty, endoluminal substances injection (ethanolamine oleate, polidocanol, botulinum toxin), stents, and certain drugs (beta-agonists, anticholinergic, nitrates, calcium channel blockers, and phosphodiesterase inhibitors).MethodsA critical review was performed.ResultsEndoscopic, surgical, and pharmacological treatments were included. A qualitative synthesis was presented.ConclusionNon-conventional therapeutic options for treating achalasia encompass medical, endoscopic, and surgical procedures. Clinicians and patients need to know all the tools for the management of achalasia. However, several currently available studies of non-conventional treatments lack high-quality evidence, and future randomized trials are still needed.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
- *Correspondence: Francisco Tustumi
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Gaber CE, Eluri S, Cotton CC, Strassle PD, Farrell TM, Lund JL, Dellon ES. Epidemiologic and Economic Burden of Achalasia in the United States. Clin Gastroenterol Hepatol 2022; 20:342-352.e5. [PMID: 33652152 PMCID: PMC8390595 DOI: 10.1016/j.cgh.2021.02.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/06/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Achalasia is a debilitating chronic condition of the esophagus. Currently there are no national estimates on the epidemiologic and economic burden of disease. We sought to estimate trends in incidence and prevalence of achalasia by age-sex strata, and to estimate the total direct medical costs attributed to achalasia in the United States. METHODS We conducted a cohort study using two administrative claims databases: IBM MarketScan Commercial Claims and Encounters database (2001-2018; age <65) and a 20% sample of nationwide Medicare enrollment and claims (2007-2015; age ≥65). Point prevalence was calculated on the first day of each calendar year; the incidence rate captured new cases developed in the ensuing year. Utilization rates of healthcare services and procedures were reported. Mean costs per patient were calculated and standardized to the corresponding U.S. Census Bureau population data to derive achalasia-specific total direct medical costs. RESULTS The crude prevalence of achalasia per 100,000 persons was 18.0 (95% CI, 17.4, 18.7) in MarketScan and 162.1 (95% CI, 157.6, 166.6) in Medicare. The crude incidence rate per 100,000 person-years was 10.5 (95% CI, 9.9, 11.1) in MarketScan and 26.0 (95% CI, 24.9, 27.2) in Medicare. Incidence and prevalence increased substantially over time in the Medicare cohort, and increased with more advanced age in both cohorts. Utilization of achalasia-specific healthcare was high; national estimates of total direct medical costs exceeded $408 million in 2018. CONCLUSIONS Achalasia has a higher epidemiologic and economic burden in the US than previously suggested, with diagnosis particularly increasing in older patients.
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Affiliation(s)
- Charles E. Gaber
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Swathi Eluri
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cary C. Cotton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paula D. Strassle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tim M. Farrell
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Evan S. Dellon
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Maselli R, Oliva A, Badalamenti M, Galtieri PA, Belletrutti PJ, Spadaccini M, Nicoletti R, Finati E, Vetrano S, Fosso F, Correale C, Pellegatta G, Hassan C, Repici A. Single-dose versus short-course prophylactic antibiotics for peroral endoscopic myotomy: a randomized controlled trial. Gastrointest Endosc 2021; 94:922-929. [PMID: 34119499 DOI: 10.1016/j.gie.2021.05.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) has been recommended for achalasia treatment. To prevent the potential of infective risk, antibiotic prophylaxis is usually administered, whereas the additional need of antibiotic therapy after POEM is uncertain. The primary endpoint was to determine whether prophylaxis versus prophylaxis plus short therapy was needed after POEM. METHODS Consecutive patients scheduled for POEM were randomly assigned (1:1) to group A (prophylactic cefazolin 2 g IV) or group B (prophylaxis + cefazolin 2 g IV × 3 followed by oral amoxicillin/clavulanate 3 g/day). Infective risk was assessed by means of host response, namely body temperature and serum levels of white blood cells and C-reactive protein; immune response (the cytokines interleukin [IL]-6, IL-1β, and tumor necrosis factor-α and microbial translocation mediators lipopolysaccharide binding protein and soluble CD14); and blood cultures at time points before (t0) and after (t1, t2) POEM. RESULTS After POEM, none of the 124 enrolled patients (54.6 ± 12.6 years old; 64 men) developed any fever (body temperature: t0, 36.56± .49°C; t1, 36.53± .52°C; t2, 36.48± .41°C), without any differences between groups at any time point. Regarding systemic inflammation, no difference was reported between groups in serum levels of C-reactive protein and white blood cells. Considering microbial translocation mediated response, lipopolysaccharide binding protein (group A: t0, 1539 ± 168.6 pg/mL; t1, 1321 ± 149.1 pg/mL; t2, 2492 ± 283.2 pg/mL; group B: t0, 1318 ± 115.9 pg/mL; t1, 1492 ± 163.8 pg/mL; t2, 2600 ± 328.2 pg/mL) and soluble CD14 (group A: t0, 2.16 ± .15 μg/mL; t1, 1.89 ± .15 μg/mL; t2, 2.2 ± .15 μg/mL; group B: t0, 2.1 ± .13 μg/mL; t1, 2 ± .13 μg/mL; t2, 2.5 ± .2 μg/mL) were similar between the 2 groups; the immune response cytokines IL-6, IL-1β, and tumor necrosis factor-α also were similar in the 2 groups. In relation to blood cultures, at t1 the group B bacteremia rate was 3.2% (2/62) and group A was 1.6% (1/62) with no difference (P = .6). All subsequent blood cultures were negative at t2. CONCLUSIONS According to our study, postprophylactic short-term antimicrobial therapy after POEM is not required because of a very low residual infective risk. (Clinical trial registration number: NCT03587337.).
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Affiliation(s)
- Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Rome, Italy
| | - Matteo Badalamenti
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Paul James Belletrutti
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Rosangela Nicoletti
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Elena Finati
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Federica Fosso
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Carmen Correale
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
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Tashiro J, Petrosyan M, Kane TD. Current management of pediatric achalasia. Transl Gastroenterol Hepatol 2021; 6:33. [PMID: 34423154 DOI: 10.21037/tgh-20-215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022] Open
Abstract
Achalasia is a rare condition affecting esophageal motility in children. In a manner similar to the disease found in the adult population, children experience symptoms of dysphagia, regurgitation, and chest pain due to a failure of relaxation of the lower esophageal sphincter. Standard diagnostic approaches include upper endoscopy and esophageal manometry. New developments in diagnosis include high-resolution esophageal manometry and the endoscopic functional lumen imaging probe. Therapies available include endoscopic balloon dilations and botulinum toxin injections into the lower esophageal sphincter, as well as surgical interventions. The Heller myotomy was first described in 1913; since then, there have been many modifications to the procedure to improve outcomes and lower morbidity. Currently, the most commonly performed surgical procedure is the laparoscopic Heller myotomy, in which the sphincter muscle is divided using longitudinal incisions with or without a partial fundoplication procedure. In recent years, per oral endoscopic myotomy (POEM) is gaining support as a viable natural orifice therapy for achalasia. Complications of POEM occur at a relatively low rate, and outcomes following the procedure have been promising. The treatment of end-stage achalasia however, may include partial or total esophagectomy with reconstruction if possible. Future research is focused primarily on increasing the efficacy, and lowering complications, of existing therapeutic modalities.
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Affiliation(s)
- Jun Tashiro
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
| | - Mikael Petrosyan
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
| | - Timothy D Kane
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
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Tustumi F, de Sousa JHB, Dornelas NM, Rosa GM, Steinman M, Bianchi ET. The Mechanisms for the Association of Cancer and Esophageal Dysmotility Disorders. Med Sci (Basel) 2021; 9:32. [PMID: 34064058 PMCID: PMC8163009 DOI: 10.3390/medsci9020032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/12/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Achalasia and other esophageal dysmotility disorders mimicking achalasia can be associated with cancer. This study aimed to review the main mechanisms for which cancer may develop in esophageal dysmotility disorder patients. METHODS A narrative review was performed. RESULTS The mechanism for developing squamous cell carcinoma and adenocarcinoma are discussed. Besides, achalasia-like syndromes related to familial KIT-gene mutation and pseudoachalasia are discussed. CONCLUSIONS Knowing the main mechanism for which achalasia can be related to cancer is essential for clinicians to conduct the proper investigation, surveillance, and treatment.
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Affiliation(s)
- Francisco Tustumi
- Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil; (J.H.B.d.S.); (N.M.D.); (G.M.R.); (M.S.); (E.T.B.)
- Department of Gastroenterology, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-000, Brazil
| | | | - Nicolas Medeiros Dornelas
- Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil; (J.H.B.d.S.); (N.M.D.); (G.M.R.); (M.S.); (E.T.B.)
| | - Guilherme Maganha Rosa
- Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil; (J.H.B.d.S.); (N.M.D.); (G.M.R.); (M.S.); (E.T.B.)
| | - Milton Steinman
- Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil; (J.H.B.d.S.); (N.M.D.); (G.M.R.); (M.S.); (E.T.B.)
| | - Edno Tales Bianchi
- Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil; (J.H.B.d.S.); (N.M.D.); (G.M.R.); (M.S.); (E.T.B.)
- Department of Gastroenterology, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-000, Brazil
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Scoping Review and Bibliometric Analysis of the Most Influential Publications in Achalasia Research from 1995 to 2020. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8836395. [PMID: 33628819 PMCID: PMC7884120 DOI: 10.1155/2021/8836395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 02/05/2023]
Abstract
Objective To identify and evaluate characteristics of the most influential articles in achalasia research during the period 1995-2020. Methods Articles in Scopus, Web of Science Core Collection (WoSCC), and PubMed were scanned from 1995 to 2020 with achalasia as the keyword. We retrieved the articles that met all criteria by descending order after using EndNote to remove the duplicated references. Our bibliometric analysis highlighted publication year, country, journals, and networks of keywords. Results Fifteen percent of the top 100 most-cited articles were published in Annals of Surgery. They were performed in 15 countries, and most (n = 55) were from the USA. The number of citations of the 482 articles ranged from 30 to 953, 38 of which had been published in American Journal of Gastroenterology. Those articles were from 31 countries, and most of the studies (n = 217) had been performed in the USA. Most of articles (n = 335) were clinical research. Treatments were hotspots in the field of achalasia in the past years. The most influential title words were “achalasia,” “esophagomyotomy,” “pneumatic dilation,” and “lower esophageal sphincter.” Conclusion Our study offers a historical perspective on the progress of achalasia research and identified the most significant evolution in this field. Results showed treatment was the most influence aspect in achalasia.
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Nakane S, Mukaino A, Ihara E, Ogawa Y. Autoimmune gastrointestinal dysmotility: the interface between clinical immunology and neurogastroenterology. Immunol Med 2020; 44:74-85. [DOI: 10.1080/25785826.2020.1797319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Akihiro Mukaino
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Eikichi Ihara
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Grobman ME, Schachtel J, Gyawali CP, Lever TE, Reinero CR. Videofluoroscopic swallow study features of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1954-1963. [PMID: 31381208 PMCID: PMC6766503 DOI: 10.1111/jvim.15578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 07/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) disorders causing functional obstruction are rare causes of ME that may respond to targeted treatment. Functional LES disorders are reported rarely in dogs because of challenges in diagnostic methodologies. Hypothesis/Objectives To identify dogs with videofluoroscopic swallow study (VFSS) features of LES achalasia‐like syndrome (LES‐AS). We hypothesized that dogs with LES‐AS could be distinguished from normal dogs using standardized VFSS criteria. Animals Dogs with LES‐AS by VFSS (n = 19), healthy normal dogs (n = 20). Methods Retrospective study. One‐hundred thirty dogs presented to the University of Missouri Veterinary Health Center (MU‐VHC) between April 2015 and December 2017 for a free‐feeding VFSS; 20 healthy dogs were included as controls. Swallow studies were evaluated for failure of the LES to relax during pharyngeal swallow (LES‐AS). Affected dogs subsequently were evaluated using standardized criteria to identify metrics important for identifying and characterizing dogs with LES‐AS. Results Nineteen dogs with LES‐AS were identified out of 130 VFSS. Megaesophagus was present in 14 of 19 (73.7%) dogs with LES‐AS. A baseline esophageal fluid‐line and “bird beak” were present in 68.4% (95% confidence interval [CI], 47.5%‐89.3%) and 63.2% (95% CI, 41.5%‐84.8%) of affected dogs, respectively. The esophagus was graded as acontractile (8/19), hypomotile (8/19), or hypermotile (3/19). Conclusions and Clinical Importance Dogs with LES‐AS may successfully be identified by VFSS using a free‐feeding protocol. These data are of critical clinical importance because a subpopulation of dogs with functional LES obstruction may be candidates for targeted intervention.
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Affiliation(s)
- Megan E Grobman
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
| | | | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Teresa E Lever
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri
| | - Carol R Reinero
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
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Evaluation of Baseline Impedance During Water-perfused High Resolution Impedance Manometry in Patients With Symptomatic GERD. J Clin Gastroenterol 2019; 53:350-354. [PMID: 30439758 DOI: 10.1097/mcg.0000000000001147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
GOALS We aimed to investigate the hypothesis whether baseline impedance measured during water-perfused high resolution impedance manometry (HRIM) can help discriminate patients with reflux symptoms from the controls and predict the response to the proton pump inhibitors (PPIs). BACKGROUND/AIM Baseline impedance measured during solid-state HRIM can reliably discriminate patients with gastroesophageal reflux disease (GERD) from controls. STUDY We enrolled consecutive patients with typical reflux symptoms and healthy controls for the measurement of baseline impedance during the landmark period of HRIM. All patients were given PPIs and PPI response was assessed after 8 weeks of the treatment. RESULTS Baseline mucosa impedance measured during HRIM was lower in GERD patients than the controls (1861±183 vs. 3371±250 Ω; P<0.001). Baseline impedance during water-perfused HRIM had moderate diagnostic accuracy for differentiating symptomatic GERD with an area under the curve of 0.853 on receiver operating characteristics analysis. A threshold of 2530 Ω for baseline impedance had a sensitivity of 88.3% and specificity of 82.4% for GERD with a positive predictive value of 83.4% and negative predictive value of 87.6%. Among symptomatic GERD patients, poor PPI responders had higher baseline impedance than those without it (2340±260 vs. 1479±189 Ω; P=0.02). BMI negatively correlated to base impedance in either controls (r=-0.59; P=0.012) or GERD patients (r=-0.47; P=0.047). CONCLUSIONS Baseline impedance measurement during water-perfused HRIM helps differentiate patients with typical reflux symptoms from controls and also serves as a potential utility in predicting PPI response.
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Blais P, Bennett MC, Gyawali CP. Upper esophageal sphincter metrics on high-resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2019; 31:e13558. [PMID: 30815910 DOI: 10.1111/nmo.13558] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM), particularly nadir UES residual pressure (UES-RP), are abnormal in achalasia and may help characterize the underlying mechanism or predict management outcome in esophagogastric junction outflow obstruction (EGJOO). METHODS A database of consecutive patients undergoing esophageal HRM from 2008 to 2013 yielded 134 patients (59.8 ± 1.4 years, 68% F) with EGJOO. Final clinical diagnoses and treatment response were extracted from chart review. Esophageal body, UES, and lower esophageal sphincter (LES) metrics were compared between EGJOO and asymptomatic healthy controls (n = 16, 27.7 ± 0.7 years, 56% F). Logistic regression evaluated differences between HRM metrics amongst etiologies of EGJOO grouped into motor versus mechanical disorders. KEY RESULTS Distal contractile integral, distal latency, and nadir UES-RP were significantly different between EGJOO subgroups (P ≤ 0.01 for each comparison), but only nadir UES-RP remained independently predictive of subgroups (adjusted odds ratio 1.15, 95% confidence intervals 1.05-1.27, P < 0.01). Nadir UES-RP was highest in achalasia variants, and lowest in mechanical EGJOO and controls (P < 0.001). Of 19 patients who underwent LES myotomy, durable benefit was reported by 68.4% over mean 3.6 years of follow-up. Significantly higher nadir UES-RP was noted with symptom relief (3.4 vs -0.7 mm Hg with symptom recurrence, 95% confidence intervals of difference = 1.35-6.83). A threshold UES-RP of ≥2.0 mm Hg yielded a sensitivity of 84.6% and specificity of 83.3% in predicting symptom resolution following myotomy. CONCLUSIONS AND INFERENCES Nadir UES-RP offers clues to differentiation of subtypes within EGJOO and may predict symptom outcome from myotomy.
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Affiliation(s)
- Pierre Blais
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
| | - Michael C Bennett
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
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Grobman ME, Hutcheson KD, Lever TE, Mann FA, Reinero CR. Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1423-1433. [PMID: 30968469 PMCID: PMC6524387 DOI: 10.1111/jvim.15476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) achalasia is a rare cause of ME that may respond to targeted intervention. Dogs with lower esophageal sphincter achalasia‐like syndrome (LES‐AS) have been described recently, warranting investigation of analogous targeted treatment. Hypothesis/Objectives Evaluate response of dogs with LES‐AS to LES mechanical dilation and botulinum toxin A (BTA) injections, with or without surgical myotomy and fundoplication. We hypothesized that clinical and videofluoroscopic swallow study (VFSS) features of LES‐AS would improve after treatment targeting functional LES obstruction. Animals Fourteen client‐owned dogs with LES‐AS diagnosed by VFSS. Methods Retrospective study. Dogs diagnosed with LES‐AS underwent treatment between April 2015 and December 2017. Outcome measures included client perception of clinical severity, body weight (BW), body condition score (BCS), regurgitation frequency, and VFSS parameters (ME, esophageal motility, gastric filling). Dogs with positive responses were considered candidates for LES myotomy with fundoplication. Results By a median IQR of 21 (IQR, 14‐25) days after mechanical dilation and BTA, clients reported clinical improvement in 100% of dogs, BW increased 20.4% (IQR, 12.7%‐25%), pre‐ and post‐treatment BCS was 3 (IQR, 3‐4) and 5 (IQR, 4‐5), respectively, and frequency of regurgitation decreased by 80% (IQR, 50%‐85%). Duration of effect was 40 (IQR, 17‐53) days. Despite clinical improvement, ME and abnormal esophageal motility persisted in 14 dogs. Six dogs subsequently underwent myotomy and fundoplication and maintained improvement observed after mechanical dilation and BTA. Conclusions and Clinical Importance Dogs with LES‐AS experienced significant, temporary, clinical improvement after mechanical dilation and BTA. Preliminary results suggest myotomy with fundoplication provide lasting clinical benefit despite persistence of ME.
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Affiliation(s)
- M E Grobman
- Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri
| | - K D Hutcheson
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - T E Lever
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri Columbia School of Medicine Ringgold Standard Institution, Columbia, Missouri
| | - F A Mann
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - C R Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
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Salvador R, Provenzano L, Capovilla G, Briscolini D, Nicoletti L, Valmasoni M, Moletta L, Merigliano S, Costantini M. Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients. J Laparoendosc Adv Surg Tech A 2019; 30:97-102. [PMID: 30892984 DOI: 10.1089/lap.2019.0035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). Materials and Methods: The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Results: Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group (P < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group (P < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients (P = n.s.). Conclusions: Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.
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Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Dario Briscolini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Loredana Nicoletti
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
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Mauro A, Quader F, Tolone S, Savarino E, De Bortoli N, Franchina M, Gyawali CP, Penagini R. Provocative testing in patients with jackhammer esophagus: evidence for altered neural control. Am J Physiol Gastrointest Liver Physiol 2019; 316:G397-G403. [PMID: 30543463 DOI: 10.1152/ajpgi.00342.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Jackhammer esophagus (JE) is a hypercontractile disorder, the pathogenesis of which is incompletely understood. Multiple rapid swallows (MRS) and rapid drink challenge (RDC) are complementary tests used during high-resolution manometry (HRM) that evaluate inhibitory and excitatory neuromuscular function and latent obstruction, respectively. Our aim was to evaluate esophageal pathophysiology using MRS and RDC in 83 JE patients (28 men; median age: 63 yr; IQR: 54-70 yr). Twenty-one healthy subjects (11 men; median age: 28 yr; range: 26-30 yr) were used as a control group. All patients underwent solid-state HRM with ten 5-ml single swallows (SS) and one to three 10-ml MRS; 34 patients also underwent RDC. Data are shown as median (interquartile range). Abnormal motor inhibition was noted during at least one MRS test in 48% of JE patients compared with 29% of controls ( P = 0.29). Mean distal contractile integral (DCI) after MRS was significantly lower than after SS [6,028 (3,678-9,267) mmHg·cm·s vs. 7,514 (6,238-9,197) mmHg·cm·s, P = 0.02], as was highest DCI ( P < 0.0001). Consequently, 66% of JE patients had no contraction reserve. At least one variable of obstruction during RDC (performed in 34 patients) was outside the normal range in 25 (74%) of JE patients. Both highest DCI after SS and pressure gradient across the esophagogastric junction (EGJ) during RDC were higher in patients with dysphagia versus those without ( P = 0.04 and 0.01, respectively). Our data suggest altered neural control in JE patients with heterogeneity in inhibitory function. Furthermore, some patients had latent EGJ obstruction during RDC, which correlated with the presence of dysphagia. NEW & NOTEWORTHY Presence of abnormal inhibition was observed during multiple rapid swallows (MRS) in some but not all patients with jackhammer esophagus (JE). Unlike healthy subjects, JE patients were more strongly stimulated after single swallows than after MRS. An obstructive pattern was frequently observed during rapid drink challenge (RDC) and was related to presence of dysphagia. MRS and RDC during high-resolution manometry are useful to show individual pathophysiological patterns in JE and may guide optimal therapeutic strategies.
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Affiliation(s)
- Aurelio Mauro
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano , Milan , Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan , Italy
| | - Farhan Quader
- Division of Gastroenterology, Washington University School of Medicine , St. Louis, Missouri
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples , Naples , Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Nicola De Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Cisanello Hospital , Pisa , Italy
| | - Marianna Franchina
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano , Milan , Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan , Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine , St. Louis, Missouri
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano , Milan , Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan , Italy
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18
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Anti-ganglionic AChR antibodies in Japanese patients with motility disorders. J Gastroenterol 2018; 53:1227-1240. [PMID: 29766276 DOI: 10.1007/s00535-018-1477-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The existence of several autoantibodies suggests an autoimmune basis for gastrointestinal (GI) dysmotility. Whether GI motility disorders are features of autoimmune autonomic ganglionopathy (AAG) or are related to circulating anti-ganglionic acetylcholine receptor (gAChR) antibodies (Abs) is not known. The aim of this study was to determine the associations between autonomic dysfunction, anti-gAChR Abs, and clinical features in patients with GI motility disorders including achalasia and chronic intestinal pseudo-obstruction (CIPO). METHODS First study: retrospective cohort study and laboratory investigation. Samples from 123 patients with seropositive AAG were obtained between 2012 and 2017. Second study: prospective study. Samples from 28 patients with achalasia and 14 patients with CIPO were obtained between 2014 and 2016, and 2013 and 2017, respectively. In the first study, we analyzed clinical profiles of seropositive AAG patients. In the second study, we compared clinical profiles, autonomic symptoms, and results of antibody screening between seropositive, seronegative achalasia, and CIPO groups. RESULTS In the first study, we identified 10 patients (8.1%) who presented with achalasia, or gastroparesis, or paralytic ileus. In the second study, we detected anti-gAChR Abs in 21.4% of the achalasia patients, and in 50.0% of the CIPO patients. Although patients with achalasia and CIPO demonstrated widespread autonomic dysfunction, bladder dysfunction was observed in the seropositive patients with CIPO as a prominent clinical characteristic of dysautonomia. CONCLUSIONS These results demonstrate a significant prevalence of anti-gAChR antibodies in patients with achalasia and CIPO. Anti-gAChR Abs might mediate autonomic dysfunction, contributing to autoimmune mechanisms underlying these GI motility disorders.
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Randall DR, Evangelista LM, Kuhn MA, Belafsky PC. Improved symptomatic, functional, and fluoroscopic outcomes following serial "series of three" double-balloon dilation for cricopharyngeus muscle dysfunction. J Otolaryngol Head Neck Surg 2018; 47:35. [PMID: 29764478 PMCID: PMC5952613 DOI: 10.1186/s40463-018-0278-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/29/2018] [Indexed: 11/22/2022] Open
Abstract
Background Cricopharyngeus muscle dysfunction (CPMD) is a common cause of dysphagia. We employ a progressive series of three double-balloon dilations separated by 4–6 weeks between procedures as a primary treatment option. The purpose of this study was to evaluate subjective, functional and objective improvement in swallowing after three serial dilations for CPMD. Methods We retrospectively evaluated patients between June 1, 2014, and June 30, 2016, who underwent a series of three double-balloon dilations for CPMD. Pre- and post-dilation Eating Assessment Tool-10 (EAT-10), Functional Oral Intake Scale (FOIS), pharyngeal constriction ratio, pharyngeal area, and pharyngoesophageal segment (PES) opening were compared. Results Seventeen patients with CPMD underwent serial double-balloon dilation procedures separated by one month. Mean age of the cohort was 73.5 (SD ± 13.3) years, and 53% were female. The mean EAT-10 improved from 24.7 (SD ± 7.8) to 15.9 (SD ± 10.2) [p = 0.0021]. Mean FOIS improved from 5.4 (SD ± 1.4) pre- to 6.3 (SD ± 0.9) post-treatment (p = 0.017). Mean UES opening increased from 1.05 (SD ± 0.34) cm to 1.48 (SD ± 0.41) cm (p = 0.0003) in the anteroposterior fluoroscopic view and from 0.58 (SD ± 0.18) to 0.76 (SD ± 0.30) cm (p = 0.018) in the lateral view. Pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength, improved from 0.49 (SD ± 0.37) to 0.24 (SD ± 0.15) (p = 0.015), however pharyngeal area (PA) was unchanged. Conclusions A progressive series of three double-balloon dilations for cricopharyngeus muscle dysfunction resulted in improved patient reported dysphagia symptom scores and objective fluoroscopic swallowing parameters.
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Affiliation(s)
- Derrick R Randall
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA. .,Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, T2W 3K2, Canada.
| | - Lisa M Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Maggie A Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
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Gyawali CP, Bortoli N, Clarke J, Marinelli C, Tolone S, Roman S, Savarino E. Indications and interpretation of esophageal function testing. Ann N Y Acad Sci 2018; 1434:239-253. [DOI: 10.1111/nyas.13709] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/10/2018] [Accepted: 03/14/2018] [Indexed: 12/18/2022]
Affiliation(s)
- C. Prakash Gyawali
- Department of Medicine, Division of GastroenterologyWashington University School of Medicine St. Louis Missouri
| | - Nicola Bortoli
- Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of Pisa Pisa Italy
| | - John Clarke
- Department of Medicine, Division of GastroenterologyStanford University San Francisco California
| | - Carla Marinelli
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological SciencesUniversity of Padua Padua Italy
| | - Salvatore Tolone
- Division of Surgery, Department of SurgeryUniversity of Campania – Luigi Vanvitelli Caserta Italy
| | - Sabine Roman
- Université de Lyon, Hospices Civils de LyonDigestive Physiology, Hopital E Herriot Lyon France
- Université de LyonLyon I University, Digestive Physiology Lyon France
- Université de Lyon Inserm U1032, LabTAU Lyon France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological SciencesUniversity of Padua Padua Italy
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The natural history of achalasia: Evidence of a continuum-"The evolutive pattern theory". Dig Liver Dis 2018; 50:342-347. [PMID: 29208549 DOI: 10.1016/j.dld.2017.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/02/2017] [Accepted: 11/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is currently unclear if the three manometric patterns of esophageal achalasia represent distinct entities or part of a disease continuum. The study's aims were: a) to test the hypothesis that the three patterns represent different stages in the evolution of achalasia; b) to investigate whether manometric patterns change after Laparoscopic-Heller-Dor (LHD). METHODS We assessed the patients diagnosed with achalasia who underwent LHD as their first treatment from 1992 to 2016. Their symptoms were scored using a detailed questionnaire for dysphagia, food-regurgitation, and chest pain. Barium-swallow, endoscopy, and esophageal-manometry were performed before and 6 months after surgery. RESULTS The study population consisted of 511 patients (M:F=283:228). Patients' demographic and clinical data showed that those with pattern III had a shorter history of symptoms, a higher incidence of chest pain, and a less dilated gullet (p<0.001). All patients with a sigmoid-shaped mega-esophagus had pattern I achalasia. One patient with a diagnosis of pattern III achalasia developed pattern II at a follow-up manometry before surgery. At a median follow-up of 30 months (IQR 12-56), the outcome of surgery was positive in 479 patients (91.7%). All patients with pattern I preoperatively had the same pattern after LHD, whereas more than 50% of patients with pattern III before treatment showed pattern I or II after surgery. CONCLUSIONS This study supports the hypothesis/theory that the different manometric patterns represent different stages in the evolution of the disease-where pattern III is the earliest stage, pattern II an intermediate stage, and pattern I the final stage.
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Chandra R, Kesavan A. Progressive Dysphagia in an Adolescent Female. Clin Pediatr (Phila) 2018; 57:491-493. [PMID: 28770622 DOI: 10.1177/0009922817724401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Anil Kesavan
- 2 Rush University Medical Center, Chicago, IL, USA
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Blais P, Patel A, Sayuk GS, Gyawali CP. Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM) differentiate achalasia subtypes. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13136. [PMID: 28707402 PMCID: PMC5690813 DOI: 10.1111/nmo.13136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/22/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The upper esophageal sphincter (UES) reflexively responds to bolus presence within the esophageal lumen, therefore UES metrics can vary in achalasia. METHODS Within consecutive patients undergoing esophageal high-resolution manometry (HRM), 302 patients (58.2±1.0 year, 57% F) with esophageal outflow obstruction were identified, and compared to 16 asymptomatic controls (27.7±0.7 year, 56% F). Esophageal outflow obstruction was segregated into achalasia subtypes 1, 2, and 3, and esophagogastric junction outflow obstruction (EGJOO with intact peristalsis) using Chicago Classification v3.0. UES and lower esophageal sphincter (LES) metrics were compared between esophageal outflow obstruction and normal controls using univariate and multivariate analysis. Linear regression excluded multicollinearity of pressure metrics that demonstrated significant differences across individual subtype comparisons. KEY RESULTS LES integrated relaxation pressure (IRP) had utility in differentiating achalasia from controls (P<.0001), but no utility in segregating between subtypes (P=.27). In comparison to controls, patients collectively demonstrated univariate differences in UES mean basal pressure, relaxation time to nadir, recovery time, and residual pressure (UES-RP) (P≤.049). UES-RP was highest in type 2 achalasia (P<.0001 compared to other subtypes and controls). In multivariate analysis, only UES-RP retained significance in comparison between each of the subgroups (P≤.02 for each comparison). Intrabolus pressure was highest in type 3 achalasia; this demonstrated significant differences across some but not all subtype comparisons. CONCLUSIONS AND INFERENCES Nadir UES-RP can differentiate achalasia subtypes within the esophageal outflow obstruction spectrum, with highest values in type 2 achalasia. This metric likely represents a surrogate marker for esophageal pressurization.
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Affiliation(s)
- Pierre Blais
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, NC
| | - Gregory S. Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO,John Cochran Veterans Affairs Medical Center, St. Louis, MO
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO
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Savarino E, Bredenoord AJ, Fox M, Pandolfino JE, Roman S, Gyawali CP. Expert consensus document: Advances in the physiological assessment and diagnosis of GERD. Nat Rev Gastroenterol Hepatol 2017; 14:665-676. [PMID: 28951582 DOI: 10.1038/nrgastro.2017.130] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GERD is a common condition worldwide. Key mechanisms of disease include abnormal oesophagogastric junction structure and function, and impaired oesophageal clearance. A therapeutic trial of acid-suppressive PPI therapy is often the initial management, with endoscopy performed in the setting of alarm symptoms and to exclude other conditions. If symptoms persist and endoscopy does not reveal evidence of GERD, oesophageal function tests are performed, including oesophageal manometry and ambulatory reflux monitoring. However, reflux episodes can be physiological, and some findings on endoscopy and manometry can be encountered in asymptomatic individuals without GERD symptoms. The diagnosis of GERD on the basis of functional oesophageal testing has been previously reported, but no updated expert recommendations on indications and the interpretation of oesophageal function testing in GERD has been made since the Porto consensus over a decade ago. In this Consensus Statement, we aim to describe modern oesophageal physiological tests and their analysis with an emphasis on establishing indications and consensus on interpretation parameters of oesophageal function testing for the evaluation of GERD in clinical practice. This document reflects the collective conclusions of the international GERD working group, incorporating existing data with expert consensus opinion.
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Affiliation(s)
- Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128 Padova, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, Netherlands
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, 4016 Basel, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 St. Clair Street, Chicago, Illinois 60611, USA
| | - Sabine Roman
- Digestive Physiology, Hopital Edouard Herriot - Pavillon L, 5 Place d'Arsonval, 69437 Lyon Cedex 03, Lyon, France
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St. Louis, 660 South Euclid Avenue, St. Louis, Missouri 63110, USA
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Gotfried J, Kataria R, Schey R. Review: The Role of Cannabinoids on Esophageal Function-What We Know Thus Far. Cannabis Cannabinoid Res 2017; 2:252-258. [PMID: 29098187 PMCID: PMC5665514 DOI: 10.1089/can.2017.0031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The endocannabinoid system (ECS) primarily consists of cannabinoid receptors (CBRs), endogenous ligands, and enzymes for endocannabinoid biosynthesis and inactivation. Although the presence of CBRs, both CB1 and CB2, as well as a third receptor (G-protein receptor 55 [GPR55]), has been established in the gastrointestinal (GI) tract, few studies have focused on the role of cannabinoids on esophageal function. To date, studies have shown their effect on GI motility, inflammation and immunity, intestinal and gastric acid secretion, nociception and emesis pathways, and appetite control. Given the varying and sometimes limited efficacy of current medical therapies for diseases of the esophagus, further understanding and investigation into the interplay of the ECS on esophageal health and disease may present new therapeutic modalities that may help advance current treatment options. In this brief review, the current understanding of the ECS role in various esophageal functions and disorders is presented.
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Affiliation(s)
- Jonathan Gotfried
- Department of Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Rahul Kataria
- Department of Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Ron Schey
- Department of Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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Abstract
PURPOSE OF REVIEW Neurointestinal diseases are increasingly recognized as causes of significant gastrointestinal morbidity in children. This review highlights the most common pediatric enteric neuropathies and their diagnosis and management, emphasizing insights and discoveries from the most recent literature available. RECENT FINDINGS The embryologic and histopathologic causes of enteric neuropathies are varied. They range from congenital aganglionosis in Hirschsprung disease, to autoimmune-mediated loss of neuronal subtypes in esophageal achalasia and Chagas disease, to degenerative neuropathies in some cases of chronic intestinal pseudo-obstruction and gastroparesis. Increased awareness of the clinical presentation and diagnostic evaluation of these conditions is essential as it allows for earlier initiation of treatment and improved outcomes. Most current therapies, which include medical management, neurostimulation, and operative intervention, aim to minimize the symptoms caused by these conditions. The evidence base for many of these treatments in children is poor, and multiinstitutional prospective studies are needed. An innovative therapy on the horizon involves using neuronal stem cell transplantation to treat the underlying disorder by replacing the missing or damaged neurons in these diseases. SUMMARY Although recent advances in basic and clinical neurogastroenterology have significantly improved our awareness and understanding of enteric neuropathies, the efficacy of current treatment approaches is limited. The development of novel therapies, including pharmacologic modulators of neurointestinal function, neurostimulation to enhance gut motility, and neuronal cell-based therapies, is essential to improve the long-term outcomes in children with these disorders.
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Affiliation(s)
- Maggie L. Westfal
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Allan M. Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA
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Tancredi A, Cuttitta A, Scaramuzzi R, Scaramuzzi G, Taurchini M. Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication. Eurasian J Med 2017; 49:1-6. [PMID: 28416923 DOI: 10.5152/eurasianjmed.2017.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series. MATERIALS AND METHODS From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed. RESULTS The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001). CONCLUSION The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.
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Affiliation(s)
- Antonio Tancredi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Emergency, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Antonello Cuttitta
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Roberto Scaramuzzi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Emergency, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Thoracic Surgery, Second University of Naples, Naples, Italy
| | - Gerardo Scaramuzzi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Marco Taurchini
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
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Abstract
Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.
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Affiliation(s)
- Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100119, Gainesville, Florida 32610.
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Current status of achalasia management: a review on diagnosis and treatment. J Gastroenterol 2017; 52:401-406. [PMID: 28188367 DOI: 10.1007/s00535-017-1314-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achalasia is a rare esophageal motility disorder that is characterized by loss of peristalsis and failure of relaxation of the lower esophageal sphincter (LES), particularly during swallowing. This review focuses on the diagnosis of esophageal motility disorders as defined by the Chicago Classification ver 3.0, and presents management options with regard to per-oral endoscopic myotomy (POEM) as the treatment of choice. METHODS A concise review of literature was performed for articles related to the management of achalasia, and this was contrasted with our institution's current practice. RESULTS Achalasia is still incompletely understood, and management is focused on establishing a proper diagnosis, and relieving the obstructive symptoms. CONCLUSIONS Achalasia should be considered when dysphagia is present, and not otherwise caused by an obstruction or inflammation, and when criteria is met as per the Chicago Classification ver 3.0. Lowering LES tone and disruption of LES can be accomplished by various methods, most notably pneumatic balloon dilatation and surgical myotomy. POEM has been gaining momentum as a first line therapy for achalasia symptoms, and can be considered an important tool for motility disorders of the esophagus.
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Huang L, Pimentel M, Rezaie A. Do Jackhammer contractions lead to achalasia? A longitudinal study. Neurogastroenterol Motil 2017; 29. [PMID: 27660053 DOI: 10.1111/nmo.12953] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/25/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Jackhammer esophagus (JE) is a rare esophageal motility disorder defined in the Chicago Classification of Esophageal Motility by presence of excessively high distal contractile integral (DCI) on high-resolution manometry (HRM), with unknown natural manometric course. We examined the development of achalasia over time in patients with JE. METHODS Through a retrospective longitudinal design, patients with Jackhammer contractions who had more than one HRM between 2005 and 2015 were identified. Any change in manometric finding was assessed for the presence of achalasia. Demographic and manometric risk factors for this progression were then sought in univariate analysis. KEY RESULTS Of 3363 HRM studies, 229 subjects had multiple manometries, accounting for 528 studies. Twelve subjects met our inclusion criteria for JE on any of the multiple tests, represented by 27 studies for a total of 347 patient-months of manometric follow-up. Subjects with JE whose manometry included impedance demonstrated consistent esophageal bolus clearance. Of 12 subjects with Jackhammer contractions, three subjects progressed to type III achalasia, over a mean of 24 months (range: 19-31 months). At the time of diagnosis with JE, impaired esophago-gastric junction relaxation was seen in all three subjects and was the only risk factor that could predict progression to achalasia (P<.01). CONCLUSIONS & INFERENCES In this unique study of the natural course of JE, we have shown that JE can progress to achalasia. Manometric findings at the time of JE diagnosis might predict this progression.
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Affiliation(s)
- L Huang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - M Pimentel
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - A Rezaie
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California
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Pharmacologic Treatment of Esophageal Dysmotility. Dysphagia 2017. [DOI: 10.1007/174_2017_127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Furuzawa-Carballeda J, Torres-Landa S, Valdovinos M&A, Coss-Adame E, Martín del Campo LA, Torres-Villalobos G. New insights into the pathophysiology of achalasia and implications for future treatment. World J Gastroenterol 2016; 22:7892-7907. [PMID: 27672286 PMCID: PMC5028805 DOI: 10.3748/wjg.v22.i35.7892] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/06/2016] [Accepted: 08/05/2016] [Indexed: 02/06/2023] Open
Abstract
Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents (herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient’s quality of life.
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Brock C, McCallum RW, Gyawali CP, Farmer AD, Frøkjaer JB, McMahon BP, Drewes AM. Neurophysiology and new techniques to assess esophageal sensory function: an update. Ann N Y Acad Sci 2016; 1380:78-90. [DOI: 10.1111/nyas.13175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/10/2016] [Accepted: 06/15/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
| | - Richard W. McCallum
- Department of Internal Medicine; Texas Tech University Health Sciences Center; El Paso Texas
| | - C. Prakash Gyawali
- Division of Gastroenterology; Washington University School of Medicine; St. Louis Missouri
| | - Adam D. Farmer
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London United Kingdom
- Department of Gastroenterology; University Hospitals of North Midlands; Stoke on Trent United Kingdom
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
| | - Barry P. McMahon
- Department of Medical Physics and Clinical Engineering; Tallaght Hospital and Trinity College; Dublin Ireland
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
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Kondaka S, Rao BL, Reddy JR, Akula R. Prosthetic rehabilitation in patient with achalasia cardia - A rare case report. J Int Soc Prev Community Dent 2016; 6:383-6. [PMID: 27583229 PMCID: PMC4981943 DOI: 10.4103/2231-0762.186793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Achalasia Cardia is an idiopathic esophageal motor disorder distinguished by the loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter. The oral manifestation of the disease is dental erosion caused by the regurgitation of the gastric contents and vomiting. A female patient aged 14 years reported to the Department of Prosthodontics, Lenora Institute of Dental Sciences, with complaints concerning aesthetics and pain in relation to several teeth. Patient gave history of loss of tooth structure over the past few years with associated sensitivity and pain in several teeth. Patient also gave history of inability to consume sufficient amount of food owing to the repeated vomiting. This paper aims to present a rare case report of achalasia cardia by rehabiliting the remaining teeth with overlay denture.
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Affiliation(s)
- Sudheer Kondaka
- Department of Prosthodontics, Lenora Institute of Dental Sciences, Rajanagaram, Rajahmundry, Andhra Pradesh, India
| | - Bathala L Rao
- Department of Prosthodontics, Lenora Institute of Dental Sciences, Rajanagaram, Rajahmundry, Andhra Pradesh, India
| | - Juturi R Reddy
- Department of Prosthodontics, Lenora Institute of Dental Sciences, Rajanagaram, Rajahmundry, Andhra Pradesh, India
| | - Rajesh Akula
- Department of Prosthodontics, Lenora Institute of Dental Sciences, Rajanagaram, Rajahmundry, Andhra Pradesh, India
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Goldstein AM, Thapar N, Karunaratne TB, De Giorgio R. Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment. Dev Biol 2016; 417:217-28. [PMID: 27059882 DOI: 10.1016/j.ydbio.2016.03.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.
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Affiliation(s)
- Allan M Goldstein
- Department of Pediatric Surgery, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| | - Tennekoon Buddhika Karunaratne
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
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