[Comparison between idiopathic achalasia and achalasia caused by Chagas' disease: a review on the publications about the subject]

Isosorbide and nifedipine for Chagas' megaesophagus: A systematic review and meta-analysis

BACKGROUND

Chagas disease is a neglected tropical disease. About 6 to 8 million people are chronically infected and 10% to 15% develop irreversible gastrointestinal disorders, including megaesophagus. Treatment focuses on improving symptoms, and isosorbide and nifedipine may be used for this purpose.

METHODOLOGY

We conducted a systematic review to evaluate the effectiveness of pharmacological treatment for Chagas' megaesophagus. We searched MEDLINE, Embase and LILACS databases up to January 2018. We included both observational studies and RCTs evaluating the effects of isosorbide or nifedipine in adult patients with Chagas' megaesophagus. Two reviewers screened titles and abstracts, selected eligible studies and extracted data. We assessed the risk of bias using NIH 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group' and RoB 2.0 tool. Overall quality of evidence was assessed using GRADE.

PRINCIPAL FINDINGS

We included eight studies (four crossover RCTs, four before-after studies). Three studies evaluated the effect of isosorbide on lower esophageal sphincter pressure (LESP), showing a significant reduction (mean difference -10.52mmHg, 95%CI -13.57 to-7.47, very low quality of evidence). Three studies reported the effect of isosorbide on esophageal emptying, showing a decrease in esophageal retention rates (mean difference -22.16%, 95%CI -29.94 to -14.38, low quality of evidence). In one study, patients on isosorbide reported improvement in the frequency and severity of dysphagia (moderate quality of evidence). Studies evaluating nifedipine observed a decrease in LESP but no effect on esophageal emptying (very low and low quality of evidence, respectively). Isosorbide had a higher incidence of headache as a side effect than nifedipine.

CONCLUSIONS

Although limited, available evidence shows that both isosorbide and nifedipine are effective in reducing esophageal symptoms. Isosorbide appears to be more effective, and its use is supported by a larger number of studies; nifedipine, however, appears to have a better tolerability profile.

TRIAL REGISTRATION

PROSPERO CRD42017055143. ClinicalTrials.gov CRD42017055143.

Trypanosoma cruzi Detection in Colombian Patients with a Diagnosis of Esophageal Achalasia

Achalasia is a motility disorder of the esophagus that might be secondary to a chronic Trypanosoma cruzi infection. Several studies have investigated esophageal achalasia in patients with Chagas disease (CD) in Latin America, but no related studies have been performed in Colombia. The goals of the present study were to determine the presence of anti-T. cruzi antibodies in patients with esophageal achalasia who visited a referral hospital in Bogotá, Colombia, and to detect the presence of the parasite and its discrete typing units (DTUs). This cross-sectional study was conducted in adult patients (18-65 years old) who were previously diagnosed with esophageal achalasia and from whom blood was drawn to assess antibodies against T. cruzi using four different serological tests. Trypanosoma cruzi DNA was detected by conventional polymerase chain reaction (cPCR) and quantitative polymerase chain reaction (qPCR). In total, 38 patients, with an average age of 46.6 years (standard deviation of ±16.2) and comprising 16 men and 22 women, were enrolled. Five (13.15%) patients were found to be positive for anti-T. cruzi antibodies by indirect immunofluorescence assay (IFA), and two patients who were negative according to IFA were reactive by both enzyme-linked immunosorbent assay and immunoblot (5.3%). Parasite DNA was detected in two of these seven patients by cPCR and in one of these by qPCR. The parasite DTU obtained was TcI. In summary, this study identified T. cruzi in Colombian patients with esophageal achalasia, indicating that digestive compromise could also be present in patients with chronic CD.

Radiological findings in megaesophagus secondary to Chagas disease: chest X-ray and esophagogram

Objective

To identify and classify the radiographic patterns of megaesophagus in Chagas disease, as seen on esophagograms and chest X-rays.

Materials and Methods

This was a prospective study of 35 patients diagnosed with esophageal disease via manometry. The changes found on esophagograms were stratified according to Rezende's classification, divided into four categories (grades I through IV) determined by the degree of dilatation and impairement of esophageal motility. We subsequently correlated that ranking with the chest X-ray findings: gastric air bubble; air-fluid level; and mediastinal widening.

Results

Among the 35 patients, the esophageal disease was classified as grade I in 9 (25.7%), grade II in 3 (8.6%), grade III in 19 (54.3%), and grade IV in 4 (11.4%). None of the patients with grade I esophageal disease showed changes on chest X-rays. In two of the three patients with grade II disease, there was no gastric air-bubble, although there were no other findings in any of the grade II patients. Of the 19 patients with grade III disease, 15 had abnormal findings on X-rays. All four patients with grade IV disease showed abnormalities.

Conclusion

The use of Rezende's classification is feasible, encompassing findings ranging from the subtle changes that characterize the initial phases of esophageal disease to the complete akinesia seen in dolicomegaesophagus. Chest X-ray findings are more common in patients with advanced stages of the disease and indicate the degree of esophageal involvement in Chagas disease.

Surgical treatment analysis of idiopathic esophageal achalasia

BACKGROUND

Idiopathic esophageal achalasia is an inflammatory disease of unknown origin, characterized by aperistalsis of the esophageal body and failure of the lower esophageal sphincter in response to swallowing, with consequent dysphagia.

AIM

To demonstrate the results of surgical therapy in these patients, evaluating the occurred local and systemic complications.

METHODS

Were studied retrospectively 32 patients, 22 of whom presented non-advanced stage of the disease (Stage I/II) and 10 with advanced disease (Stage III/IV). All of them had the clinical conditions to be submitted to surgery. The diagnoses were done by clinical, endoscopic, cardiological, radiological and esophageal manometry analysis. Pre-surgical evaluation was done with a questionnaire based on the most predisposing factors in the development of the disease and the surgical indication was based on the stage of the disease.

RESULTS

The patients with non-advanced stages were submitted to cardiomyotomy with fundoplication, wherein in the post-surgical early assessment, only one (4,4%) presented pulmonary infection, but had a good outcome. In patients with advanced disease, seven were submitted to esophageal mucosectomy preserving the muscular layer, wherein one patient (14,2%) presented dehiscence of gastric cervical esophagus anastomosis as well as pulmonary infection; all of these complications were resolved with proper specific treatment; the other three patients with advanced stage were submitted to transmediastinal esophagectomy; two of them presented hydropneumothorax with good evolution, and one of them also presented fistula of the cervical esophagogastric anastomosis, but with spontaneous healing after conservative treatment and nutritional support. The two patients with fistula of the cervical anastomosis progressed to stenosis, with good results after endoscopic dilations. In the medium and long term assessment done in 23 patients, all of them reported improvement in life quality, with return to swallowing.

CONCLUSION

The strategy proposed for the surgical treatment of idiopathic esophageal achalasia according to the stages of the disease was of great value, due to post-surgical low morbidity complications and proper recovery of swallowing.

Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus

BACKGROUND

The surgical treatment of advanced megaesophagus has no consensus, being esophagectomy the more commonly used method. Since it has high morbimortality--inconvenient for benign disease -, in recent years an alternative has been introduced: the esophageal mucosal resection.

AIM

To compare early and late results of the two techniques evaluating the operative time, length of ICU stay; postoperative hospitalization; total hospitalization; intra- and postoperative complication rates; mortality; and long-term results.

METHODS

Were evaluated retrospectively 40 charts, 23 esophagectomies and 17 mucosectomies. In assessing postoperative results, interviews were conducted by using a specific questionnaire.

RESULTS

Comparing the means of esophagectomy and mucosal resection, respectively, the data were: 1) surgical time--310.2 min and 279.7 min (p > 0.05); 2) length of stay in ICU--5 days and 2.53 days (p <0.05); 3) total time of hospitalization--24.25 days and 20.76 days (p> 0.05); 4) length of hospital stay after surgery--19.05 days and 14.94 days (p> 0.05); 5) presence of intraoperative complications--65% and 18% (p <0.05); 6) the presence of postoperative complications - 65% and 35% (p> 0.05). In the assessment of late postoperative score (range 0-10) esophagectomy (n = 5) obtained 8.8 points and 8.8 points also got mucosal resection (n = 5).

CONCLUSIONS

Esophageal mucosal resection proved to be good alternative for surgical treatment of megaesophagus. It was advantageous in the immediate postoperative period by presenting a lower average time in operation, the total hospitalization, ICU staying and complications rate. In the late postoperative period, the result was excellent and good in both operations.

Esophageal motor disorders in subjects with incidentally discovered Chagas disease: a study using high-resolution manometry and the Chicago classification

In patients with chronic indeterminate Chagas disease, conventional manometry has shown that 25-48% had esophageal motor disorders. Recently, esophageal high-resolution manometry (HRM) has revolutionized the assessment of esophageal motor function. In this study, we performed esophageal HRM in a group of subjects with incidentally positive serological findings for Trypanosoma cruzi. In this prospective observational study, we evaluated subjects who had positive serological tests for Chagas disease detected during a screening evaluation for blood donation. All subjects underwent symptomatic evaluation and esophageal HRM with a 36 solid-state catheter. Esophageal abnormalities were classified using the Chicago classification. Forty-two healthy subjects (38 males) aged 18-61 years (mean age, 40.7 years) were included. When specific symptoms questionnaire was applied, 14 (33%) subjects had esophageal symptoms. Esophageal high-resolution manometry revealed that 28 (66%) of the subjects had an esophageal motility disorder according to the Chicago classification. Most common findings were hypocontractile disorders in 18 subjects (43%) and esophagogastric junction (EGJ) outflow obstruction in 6 (15%). Esophageal high-resolution manometry reveals that up to two thirds of the subjects with an incidental diagnosis of Chagas disease have esophageal abnormalities. This technology increases the detection and allows a more complete assessment of esophageal motor function in subjects infected with T. cruzi even in the early stages of the disease.

High-resolution manometry classifications for idiopathic achalasia in patients with Chagas' disease esophagopathy

BACKGROUND

Idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) share several similarities. The comparison between IA and CDE is important to evaluate whether treatment options and their results can be accepted universally. High-resolution manometry (HRM) has proved a better diagnostic tool compared to conventional manometry. This study aims to evaluate HRM classifications for idiopathic achalasia in patients with CDE.

METHODS

We studied 98 patients: 52 patients with CDE (52 % females, mean age, 57 ± 14 years) and 46 patients with IA (54 % females; mean age 48 ± 19 years). All patients underwent a HRM and barium esophagogram.

RESULTS

The Chicago classification was distributed in IA as Chicago I, 35 %; Chicago II, 63 %; and Chicago III, 2 %, and in CDE as Chicago I, 52 %; Chicago II, 48 %; and Chicago III, 0 % (p = 0.1, 0.1, and 0.5, respectively). All patients had the classic Rochester type. CDE patients had more pronounced degrees of esophageal dilatation (p < 0.002). The degree of esophageal dilatation did not correlate with Chicago classification (p = 0.08). In nine (9 %) patients, the HRM pattern changed during the test from Chicago I to II.

CONCLUSION

Our results show that (a) HRM classifications for IA can be applied in patients with CDE and (b) HRM classifications did not correlate with the degree of esophageal dilatation. HRM classifications may reflect esophageal repletion and pressurization instead of muscular contraction. The correlation between manometric findings and treatment outcomes for CDE needs to be answered in the near future.

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high-resolution manometry

The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high-resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high-resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.

The chronic gastrointestinal manifestations of Chagas disease

Chagas disease is an infectious disease caused by the protozoan Trypanosoma cruzi. The disease mainly affects the nervous system, digestive system and heart. The objective of this review is to revise the literature and summarize the main chronic gastrointestinal manifestations of Chagas disease. The chronic gastrointestinal manifestations of Chagas disease are mainly a result of enteric nervous system impairment caused by T. cruzi infection. The anatomical locations most commonly described to be affected by Chagas disease are salivary glands, esophagus, lower esophageal sphincter, stomach, small intestine, colon, gallbladder and biliary tree. Chagas disease has also been studied in association with Helicobacter pylori infection, interstitial cells of Cajal and the incidence of gastrointestinal cancer.

[Surgically treated megaesophagus: epidemiological profile of patients operated in the Clinical Hospital of the State University of Campinas between 1989 and 2005]

Megaesophagus is one of the manifestations of Chagas disease and surgical treatment is the approach that presents the best results. In this retrospective study, the epidemiological profile of patients operated in the Clinical Hospital of University of Campinas between 1989 and 2005 was evaluated with regard to: place of birth, place of residence, probable place of infection, age, degree of megaesophagus, etiology, duration and evolution of dysphagia, other diseases in association and the type of surgery chosen. The method used was to analyze the 390 medical files of these patients, at the hospitals medical archive service. The results made it possible to establish the endemic regions, place of birth and place of residence of the patients with Chagas disease attended at our clinic, and to characterize the group. After detailed analysis, it was found that the mean age was 47 years and the mean duration of dysphagia was 9.47 years. It was observed that: a) in 84.4% of the patients, dysphagia took hold progressively; b) 306 (78.5%) patients presented Chagas disease etiology; c) grade 2 was prevalent in 48%; d) 89.8% of the patients underwent cardiomyotomy; and e) there were frequent associations with gastritis, esophagitis, megacolon, arterial hypertension and cardiopathy.

Response of the esophageal body to wet and dry swallows in Chagas' disease

BACKGROUND: Wet swallows cause a greater esophageal contraction amplitude and duration than dry swallows. In Chagas' disease there is a reduction in amplitude of esophageal contraction but we do not know if the difference between wet and dry swallows is seen in the disease. AIM: To compare the esophageal contractions after wet and dry swallows in patients with Chagas' disease. METHODS: We measured the area under the curve (amplitude x duration) of the esophageal contractions in 30 patients with a diagnosis of esophageal involvement by Chagas' disease and 44 controls. We used the manometric method with continuous perfusion. The contractions were measured at 2, 7, 12 and 17 cm below the upper esophageal sphincter, after five swallows of a 5 mL bolus of water alternated with five dry swallows. RESULTS: In the control group wet swallows caused a higher area under the curve than dry swallows. There was no difference between wet and dry swallows in Chagas' disease patients, and there was no difference in wet and dry swallows in Chagas' disease patients compared with dry swallows of controls. At 12 and 17 cm from the upper esophageal sphincter the area under the curve after wet and dry swallows in Chagas' disease patients younger than 60 years (n = 15) was higher than in Chagas' disease patients older than 60 years (n = 15). CONCLUSION: We conclude that in normal subjects there is adaptation to the presence of a liquid bolus inside the esophageal body, which does not happen in patients with Chagas' disease.

Avaliação nutricional pré-operatória dos pacientes com megaesôfago não-avançado

OBJETIVO: Avaliar o estado nutricional de pacientes com megaesôfago não-avançado no pré-operatório. MÉTODO: Foram selecionados dez pacientes adultos (seis do sexo masculino, quatro do feminino) provenientes dos Ambulatórios de Cirurgia do Hospital Regional do Vale do Paraíba-SAB e do Hospital Universitário de Taubaté. O diagnóstico do megaesôfago foi realizado por meio de um protocolo com informações referentes à origem epidemiológica, quadro clínico, sorologia para doença de Chagas, esofagrafia, endoscopia digestiva alta e eletromanometria. A avaliação do estado nutricional foi feita com dados antropométricos (Peso, IMC, CB, PCT e CMB) e bioquímicos (albumina, transferrina e linfocitometria). RESULTADOS: O peso foi o parâmetro mais comprometido, sendo a porcentagem de perda de peso considerada grave em oito pacientes. Somente um paciente classificou-se como percentil 5. Não houve alteração bioquímica significante. CONCLUSÃO: A maioria dos pacientes é eutrófica, sendo um paciente considerado desnutrido.

Differences in response of the proximal esophagus to wet swallows in patients of Chagas' disease and idiopathic achalasia

Chagas' disease and idiopathic achalasia have similar esophageal manifestations such as absent or incomplete lower esophageal sphincter relaxation and aperistalsis in the esophageal body (alterations seen mainly in the distal esophageal body). Our aim in this paper was to study the response of the proximal esophageal body to wet swallows in patients with Chagas' disease and patients with idiopathic achalasia. We retrospectively analyzed the time interval between the onset of the pharyngeal contractions 1 cm proximal to the upper esophageal sphincter, as well as 5 cm distal to the pharyngeal measurement. Amplitude, duration and area under the curve of contractions in the proximal esophagus were also determined in 42 patients with Chagas' disease (15 with associated esophageal dilatation), 21 patients with idiopathic achalasia (14 with concomitant esophageal dilatation) and 31 control subjects. The time between the onset of pharyngeal and proximal esophageal contractions was longer in patients with Chagas' disease and in those with esophageal dilatation (1.39 +/- 0.16 s) than in control subjects (0.86 +/- 0.04 s, P < 0.01). The amplitude of proximal esophageal contractions was lower in patients with idiopathic achalasia and esophageal dilatation (60.9 +/- 16.3 mmHg) than in control subjects (89.7 +/- 6.9 mmHg, P = 0.06). The authors conclude that in patients with advanced esophageal disease, the proximal esophageal contractions in Chagas' disease have a delayed response to wet swallows when compared with controls, and that the amplitude of proximal esophageal contractions was lower than expected in patients with idiopathic achalasia.

Comparison of esophageal motility impairment caused by Chagas' disease in two age groups

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean ± SE: 30.8 ± 4.3 mm Hg) than younger patients (51.9 ± 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41%) and fewer peristaltic (8%) contractions than younger patients (non-conducted: 16%, peristaltic: 21%). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.

Esophageal contractions in Chagas' disease and in idiopathic achalasia

GOALS

The aim of this study was to compare the esophageal contractions in Chagas' disease and in idiopathic achalasia.

BACKGROUND

It is suggested that the esophageal involvement caused by Chagas' disease and by idiopathic achalasia, although similar, shows some differences.

STUDY

We studied the contractions at 2, 7, 12, and 17 cm below the upper esophageal sphincter in 25 patients with idiopathic achalasia (15 with dilatation), 52 with Chagas' disease (22 with dilatation), and 18 controls. Each subject performed 5 swallows of a 5-mL bolus of water alternated with 5 dry swallows.

RESULTS

In the distal esophageal body, the amplitude was lower in patients than in controls. Among patients with esophageal dilatation, the proximal amplitude was lower in patients with idiopathic achalasia, and the time interval between the contractions at 2 and 7 cm was longer in patients with Chagas' disease, the number of failed contractions was higher in Chagas' disease, and simultaneous contractions were more frequent in idiopathic achalasia. The simultaneous isobaric pressure in the distal esophagus was associated with an increase in proximal pressure that was higher than distal but lower than proximal swallowing pressure.

CONCLUSION

The results suggested that idiopathic achalasia and Chagas' disease cause similar impairment of distal esophageal motility, but in patients with esophageal dilatation the impairment of proximal motility may be not the same.

Proximal and distal esophageal contractions in patients with vigorous or classic esophageal Chagas' disease

BACKGROUND

Some patients with achalasia have distal esophageal contraction amplitude in the normal range, a condition called vigorous achalasia, and others have low contraction amplitude, a condition named classic achalasia. The difference in distal contraction amplitude may also be associated with a difference in proximal contraction amplitude.

AIM

To study the proximal and distal esophageal contractions in patients with Chagas' disease.

MATERIAL AND METHODS

We studied 28 patients with Chagas' disease, all with dysphagia and an esophageal radiologic examination with retention without dilation, and 18 controls. The patients with Chagas' disease had vigorous achalasia (distal amplitude over 34 mm Hg, n = 13) or classic achalasia (distal amplitude below 34 mm Hg, n = 15). We measured the contractions by the manometric method with continuous perfusion at 2, 7, 12 and 17 cm below the upper esophageal sphincter after five swallows of a 5 mL bolus of water.

RESULTS

There was no difference in proximal amplitude of contractions between classic or vigorous achalasia, and controls. In the proximal esophagus there was also no difference in duration or area under curve of contractions. In the distal esophagus, duration and area under curve were lower in classic than vigorous disease. Failed and simultaneous contractions were more frequent in patients than controls. Simultaneous contractions were seen more frequently in classic disease, and peristaltic contractions were seen more frequently in vigorous disease.

CONCLUSION

We did not find differences in proximal esophageal contractions of patients with classical or vigorous esophageal Chagas' disease, except for the higher number of simultaneous contractions seen in classic disease.