Fever, cough, and bilateral lung infiltrates. Achalasia associated with aspiration pneumonia

Early-onset esophageal squamous cell carcinoma with achalasia: A case report

RATIONALE

Individuals afflicted with achalasia of the cardia (AC) are more susceptible to the development of esophageal cancer (EC). However, the presence of esophageal retention obscured observation, making it difficult to detect EC early, which leads to misdiagnosis and poor prognosis in AC patients with EC. Besides, the persistence of high-risk factors may have contributed to the rapid progression of EC shortly after per-oral endoscopic myotomy (POEM). Therefore, it is imperative to alert clinicians to this extremely rare and instructive early-onset cancer.

PATIENT CONCERNS

The patient was a 67-year-old male who developed dysphagia 3 years ago without obvious causes, with intermittent onset and aggravating trend, accompanied by weight loss. He usually eats high-temperature foods and pickled foods, and has a family history of esophageal squamous cell carcinoma.

DIAGNOSIS AND INTERVENTIONS

The patient was initially diagnosed with AC 2 years ago and subsequently underwent POEM surgery. One year after surgery, he was found to have mid-upper EC during follow-up and underwent partial esophagectomy in time.

OUTCOMES

The patient's symptoms have significantly improved with weight gain, and he is still adhering to regular follow-up and endoscopic examination.

LESSONS

In rare cases, EC develops early in patients with achalasia after POEM surgery. To avoid missed diagnosis, a comprehensive examination to improve the accuracy to diagnose achalasia and identify possible early-onset cancer is very important in clinical practice. Especially for patients with AC who have a family history of EC or other high-risk factors may develop EC early after POEM surgery. Therefore, regular endoscopic follow-up after POEM surgery is essential.

Achalasia Subtype Differences Based on Respiratory Symptoms and Radiographic Findings

Three subtypes of achalasia have been defined using esophageal manometry. Several studies have reported that symptoms are experienced differently among men and women, regardless of subtype. All subtypes could have some impact on the appearance of respiratory symptoms and lung complications due to compression of the trachea or aspiration of undigested food. The aim of this research was to analyze the differences in respiratory symptoms and radiographic presentation of lung pathology depending on the diameter and achalasia types. One or more respiratory symptoms were reported in 48% of 114 patients, and all of them had two or more gastrointestinal symptoms. The symptom score (SS) is statistically significant for the prediction of subtype 1 (area under the curve = 0.318; p < 0.001, cut-off score of 6.5 had 95.2% sensitivity) and subtype 2 (area under the curve = 0.626; p = 0.020, cut-off score of 7.5 had 93.1% sensitivity). The most common type was subtype 2 (50.8%), and although only 14 patients had subtype 3, they had the largest esophageal diameter (mean 5.8 cm). The difference in esophageal diameter was significant between subtype 1 and 3 (p = 0.011), subtype 2 and subtype 3 (p = 0.011). Nine patients (6%) had mega-esophagus (four patients in type 1, three in type 2 and two in type 3). More than half of all patients (51.7%) had at least one parenchymal lung change on CT scan. Recurrent micro-aspirations led to changes in the structure of the airways and lung parenchyma such as ground glass (GGO) and nodular changes (12%) and fibrosis (14.5%), and they had higher esophageal diameters (p < 0.001). Patients with chronic lung CT changes had significantly higher esophageal diameter than with acute changes (p < 0.001). Awareness of the association of achalasia and lung disorders is important in early diagnosis and treatment. More than half (57.5%) of patients with achalasia had some clinical and/or structural pulmonary abnormalities. All three subtypes had similar respiratory symptoms, meaning they cannot be used to predict the subtype of achalasia; on the contrary, SS can predict the first two subtypes. A higher diameter of the esophagus is associated with chronic structural lung changes. Although unexpected, the pathological radiological findings and diameter were significantly different in subtype 3 patients, but those parameters cannot lead us to a specified subtype.

Incidence, morbidity and mortality of patients with achalasia in England: findings from a study of nationwide hospital and primary care data

BACKGROUND

Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited.

METHODS

Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality.

RESULTS

There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years.

CONCLUSION

The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.

Achalasia and esophageal cancer: risks and links

Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.

Achalasia: a risk factor that must not be forgotten for esophageal squamous cell carcinoma

Alcohol and tobacco abuse are the main risk factors for esophageal squamous cell carcinoma (ESCC), but other conditions that induce chronic irritation of the esophageal mucosa have also been attributed to it. For example, long-standing achalasia increases 16 times the risk of developing ESCC. We report the case of a patient with long-standing achalasia who developed ESCC. Although this complication is infrequent, it should be remembered by clinicians who treat patients with achalasia to detect early stages cancer.

Successful airway management in a patient with severe proximal achalasia requires interdisciplinary cooperation

We report a case of a patient undergoing esophagectomy for end-stage achalasia, a rare condition associated with potentially catastrophic ventilatory and circulatory complications. The complexity of the case necessitated preoperative planning with the surgical specialist, development of a novel algorithm for airway management, and careful implementation of our plan. Isolation of the lungs from the esophagus presented unique challenges due to not only the anatomic derangements that are the hallmark of this disease process but also an unusual anatomic finding seen in this patient.

Respiratory dysfunction is common in patients with achalasia and improves after pneumatic dilation

BACKGROUND

Dysphagia, regurgitation, and chest pain are common achalasia, with a variable report of pulmonary symptoms possibly due to micro-aspiration. Pneumatic dilation (PD) may improve pulmonary function. Data on pulmonary dysfunction among achalasia patients are scanty, and the effect of PD is unknown.

AIM

To evaluate pulmonary dysfunction in patients with achalasia based on clinical and radiologic evaluation and spirometry and to study the effect of PD at 1-month follow-up.

METHODS

Patients with achalasia (diagnosed using high-resolution manometry and the Chicago classification) were evaluated prospectively by spirometry before (n = 38) and 1 month after PD (n = 31). All patients received a chest X-ray, and patients with respiratory abnormality before PD received high-resolution computed tomography of the thorax.

RESULTS

Of the 38 patients, 17 and 21 had type I and II achalasia, respectively. The respiratory symptoms, such as pharyngeal symptoms [27/38 (71 %) vs. 8/31 (26 %); P = 0.0001], cough [23/38 (60.5 %) vs. 5/31 (16 %), P = 0.0001], and dyspnea [8/38 (21 %) vs. 0/31 (0 %), P = 0.006], improved after treatment with PD. Spirometry showed abnormalities in 17/38 (45 %) patients before and in 8/15 (53 %) after PD. Median FEV(1), FVC, PEFR, and percentage of predicted MEF(25-75), improved from 78 % (36-85), 74 % (48-100), 62 % (18-72), and 48 % (15-66) before to 83 % (58-94), 86 % (55-99), 69 % (38-81), and 59 % (33-78) after PD, respectively (P < 0.05 for all).

CONCLUSION

Respiratory symptoms and spirometry abnormalities are common in patients with achalasia and improved after successful PD.

Clinical, radiological and functional assessment of pulmonary status in patients with achalasia cardia before and after treatment

OBJECTIVES

Patients with achalasia have respiratory symptoms due to chronic microaspiration. Achalasia can lead to radiological and functional changes in the lung. We studied the effect of either balloon dilatation or laparoscopic Heller's cardiomyotomy on the reversal of these changes in the lung.

METHODS

Thirty patients with achalasia were included in this study. Oesophageal symptoms and pulmonary symptoms were recorded. Pulmonary function tests (PFTs) were done at baseline and at the end of 6 months. High-resolution computed tomography of the chest was performed prior to treatment and repeated 6 months after treatment if found abnormal at the initial evaluation.

RESULTS

The mean age of the patients was 30.97 years and mean duration of symptoms was 22.5 months. Fifteen patients (50%) had respiratory symptoms, nocturnal cough being the commonest symptom in 13 (43.3%). Thirteen patients (43.3%) had parenchymal lung changes on high-resolution computed tomography (HRCT). Eight patients (28.5%) had functional abnormalities in the lungs in the form of restrictive airway disease. Nineteen patients opted for Laparoscopic Heller's cardiomyotomy, while 11 patients underwent pneumatic dilatation. Six months after treatment, the respiratory symptoms resolved in all except two patients (13.3%). Four patients (66.6%) with active lung changes at HRCT showed resolution at 6 months. There was improvement in functional parameters on PFT evaluation with normalization of PFT in one patient.

CONCLUSIONS

Pulmonary symptoms as well as radiological and functional abnormalities are common in patients with achalasia. Treatment in the form of pneumatic dilatation or Lap cardiomyotomy improves pulmonary symptoms.

Prevalence of respiratory symptoms in patients with achalasia

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work-up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty-two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post-op follow-up questionnaire were analyzed as a subset. Ninety-five patients (86%) complained of at least daily dysphagia. Fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder.

Improvement of respiratory symptoms following Heller myotomy for achalasia

INTRODUCTION

Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms.

METHODS

We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms.

RESULTS

All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy.

CONCLUSIONS

A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

Structural and functional abnormalities in lungs in patients with achalasia

Dilatation and oesophageal body aperistalsis in achalasia can lead to stasis which in turn can induce repeated microaspiration. It is therefore conceivable that patients with achalasia may also have abnormalities in lungs secondary to repeated episodes of microaspiration. There is a lack of systematic study on involvement of lungs in patients with achalasia. Thirty patients with achalasia underwent pulmonary function tests (spirometry, and carbon mono-oxide diffusion capacity) and high resolution computerized tomography (HRCT) of the chest. The mean age of patients and mean duration of disease were 33.5 +/- 10.9 years and 28.1 +/- 27.3 months respectively. Regurgitation was present in 22 (73.3%) of them. Respiratory symptoms in them were dry cough in 17 (56.6%), and chest pain in 18 (60%). The oesophagus was dilated in 26 (86.6%) and 13 (43.3%) had residue in oesophagus. Sixteen (53.3%) patients had either anatomical changes as seen on HRCT or functional changes as observed on pulmonary function tests. Of those with functional abnormalities, five (16.6%) and one (3.3%) had restrictive and obstructive airways disease respectively. While evidence of tracheo-bronchial compression by dilated oesophagus was present in eight (26.6%), 10 (33.3%) patients had parenchymal lung disease [nodular opacities in five (16.6%), ground glass appearance six (20%), patchy pulmonary fibrosis five (16.6%), air trapping two (6.6%), consolidation and bronchiectasis one (3.3%) each]. There was a significant association between presence of regurgitation and dilatation of oesophagus (P = 0.032). More than half (53.3%) of patients with achalasia have structural and/or functional abnormalities in lungs.

Achalasia: unusual cause of chronic cough in children

Achalasia is a rare motility disorder of the esophagus which results from lack of enervation of the lower esophageal sphincter muscles and leads to dilatation of proximal esophagus. Patients with achalasia presents typically with dysphagia, vomiting of undigested food and failure to thrive. Cough can be present in achalasia patients due to aspiration of food or due to airway compression by the dilated esophagus. We report two cases of achalasia presenting primarily with prolonged cough. Diagnosis of achalasia in both cases was delayed due to this atypical presentation. This highlights the importance of recognizing achalasia as a potential cause of chronic cough in order to avoid delayed diagnosis and mismanagement.