[Upper gastrointestinal symptoms and esophageal motility disorders in indeterminate Chagas disease patients]

SYMPTOMS ASSOCIATED WITH DIFFERENT DEGREES OF MEGAESOPHAGUS IN CHAGAS DISEASE

BACKGROUND

Dysphagia is the most frequent digestive symptom in Chagas disease, although other symptoms are reported. These symptoms can be associated with the degree of radiological impairment of the esophagus and the duration of dysphagia.

OBJECTIVE

This investigation aimed to assess the symptoms and the time of dysphagia related to the different degrees of megaesophagus in patients with Chagas disease.

METHODS

A total of 29 patients aged 48 to 73 years participated in this investigation. All of them had dysphagia and a positive serum result for Chagas disease. They were submitted to the assessment of symptoms and radiological examination of the esophagus to assess the degree of megaesophagus, which ranged from I (mild change) to IV (intense change). Dysphagia was quantified with the Eating Assessment Tool (EAT-10).

RESULTS

Twelve (41%) patients had megaesophagus degree I, 9 (31%) had degree II, and 8 (28%) had degrees III (6) and IV (2). The intensity of dysphagia was not related to the result of the radiological examination, with EAT-10 median of 5.5 for the degree I, 9.0 for degree II, and 5.5 for degrees III and IV (P>0.25). Choking (14%), regurgitation (21%), voice complaint (21%), weight loss (17%), and odynophagia (17%) were not related to the degree of megaesophagus. Voice changes and odynophagia were related to the patients' time of dysphagia. Likewise, the frequency of symptoms and EAT-10 values were related to the duration of dysphagia.

CONCLUSION

The longer the patient had dysphagia, the more frequent were the symptoms reported by the patients. There was no relationship between the degrees of megaesophagus and the symptoms and intensity of dysphagia.

Manifestations and strategies of coping with Chagas Disease that interfere in the quality of life of the individual: a systematic review

We aimed to identify the manifestations and coping strategies of Chagas disease that influence the quality of life of the affected subject. This is a literature systematic review carried out in PubMed, SciELO and Lilacs databases, through which sixpapers were retrieved, in addition to six publications identified with the verification of the bibliographic list and four papers through manual search, which were independently evaluated by two reviewers. The variables addressed were set in the thematic axes manifestations of Chagas disease that interfere in the quality of life of the individual and coping strategies that influence the quality of life of patients affected by Chagas disease, subdivided into three realms, namely, physical, psychological and social. The results seen in all addressed realms evidenced a quality of life compromised by the disease, measures mostly limited to the patient's physical realm and incipient records of studies in the area. We suggest further exploring the proposed theme, believing that knowledge of the patient living with the disease promotes the development of effective health intervention strategies.

Análise do deslocamento do bolo alimentar: comparação entre o esôfago saudável e modelo de megaesôfago chagásico

RESUMO Objetivo: estudar a dinâmica do comportamento do esôfago humano quando afetado por doença de Chagas e propor um controlador orgânico para auxiliar no aperistaltismo do órgão. Métodos: um modelo de massa, mola e amortecedor foi proposto para modelar o deslocamento do bolo alimentar no esôfago durante a ação peristáltica. Foram utilizados parâmetros da literatura para simular o megaesôfago chagásico e o saudável. Resultados: foram analisadas as curvas de velocidade e deslocamento de ambos os modelos e identificou-se as diferenças dinâmicas entre o órgão saudável e um doente. O deslocamento de alimentos em um tipo de Chagas megaesófago II (3 centímetros de dilatação) é apenas 11,84% do deslocamento num esófago saudável. Conclusão: a doença de chagas gera uma velocidade próxima de zero e um alto amortecimento na curva de descida do alimento que devido ao peristaltismo o deslocamento que não pode retornar ao seu estado inicial, o que comprova a retenção do bolo alimentar. Com o sistema de controle orgânico proposto obteve-se uma aproximação das curvas a um comportamento dinâmico próximo do modelo do órgão saudável, minimizando a retenção do alimento.

Oesophageal motility disorders in infected immigrants with Chagas disease in a non-endemic European area

BACKGROUND

Immigration-related new diseases pose a growing challenge for healthcare services in receptor countries. Following Latin American migration, Chagas disease has inevitably appeared in Europe.

AIM

To determine the prevalence and characteristics of oesophageal motility disorders in immigrants infected with Trypanosoma cruzi, using high resolution oesophageal manometry (HREM).

METHODS

In all newly-diagnosed cases with chronic Chagas infection referring upper digestive symptoms, a protocolized clinical evaluation and complementary tests including barium oesophagogram and HREM were carried out. As control group, 14 healthy subjects from the same endemic areas were studied with HREM.

RESULTS

We included 61 patients (46 female, 15 male; age range 26-63 years). Only seven patients (11%) had a minor alteration on barium oesophagogram. By contrast, 23 (37%) patients showed an alteration in oesophageal manometry, mainly minor motility disorders (34%). Only one healthy control (7%) had a minor motility disorder at HREM (p = 0.029 vs. patients).

CONCLUSIONS

Oesophageal motor disorders in infected immigrants with Chagas disease are common, and mainly characterized by a minor motility disorder that is not detected by barium oesophagogram. Hence, as well as barium oesophagogram examination, HREM should be considered, to assess oesophageal damage in this specific group of patients.

High Resolution Esophageal Manometry in Patients with Chagas Disease: A Cross-Sectional Evaluation

INTRODUCTION

Gastrointestinal involvement affects 30-40% of the patients with chronic Chagas disease. Esophageal symptoms appear once the structural damage is established. Little is known about the usefulness of high resolution manometry to early identification of esophageal involvement.

METHOD

We performed a cross-sectional study at the Vall d'Hebron University Hospital (Barcelona, Spain) between May 2011 and April 2012. Consecutive patients diagnosed with Chagas disease in the chronic phase were offered to participate. All patients underwent a structured questionnaire about digestive symptoms, a barium esophagogram (Rezende classification) and an esophageal high resolution manometry (HRM). A control group of patients with heartburn who underwent an esophageal HRM in our hospital was selected.

RESULTS

62 out of 73 patients that were included in the study fulfilled the study protocol. The median age of the Chagas disease group (CG) was 37 (IQR 32-45) years, and 42 (67.7%) patients were female. Twenty-seven (43.5%) patients had esophageal symptoms, heartburn being the most frequent. Esophagogram was abnormal in 5 (8.77%). The esophageal HRM in the CG showed a pathological motility pattern in 14 patients (22.6%). All of them had minor disorders of the peristalsis (13 with ineffective esophageal motility and 1 with fragmented peristalsis). Hypotonic lower esophageal sphincter was found more frequently in the CG than in the control group (21% vs 3.3%; p<0.01). Upper esophageal sphincter was hypertonic in 22 (35.5%) and hypotonic in 1 patient. When comparing specific manometric parameters or patterns in the CG according to the presence of symptoms or esophagogram no statistically significant association were seen, except for distal latency.

CONCLUSION

The esophageal involvement measured by HRM in patients with chronic Chagas disease in our cohort is 22.6%. All the patients with esophageal alterations had minor disorders of the peristalsis. Symptoms and esophagogram results did not correlate with the HRM results.

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.

[Digestive forms of Chagas disease and carcinogenesis: a study of association]

The authors analyze the relation between gastrointestinal carcinogenesis and Chagas disease, based on detailed review of the literature. To this end, epidemiological, experimental and human material pathology description studies have been selected. The article discusses the possibility of protection being afforded by not fully known morphokinetic cellular, immune and neuroendocrine factors that would be secondary to plexus degeneration. Also aspects related to the parasite-host interaction from the viewpoint of epithelial modulation of colonic mucosa and its antitumor implications are presented. Finally, it exposes the pathophysiological mechanism of esophageal cancer development in patients with mega-organ. In conclusion, chagasic colopathy, especially the intrinsic neuronal damage, is a study model that can contribute to the understanding of colorectal carcinogenesis.

[The life of the patient with chronic Chagas disease: possible nursing actions towards a healthy life]

This study, carried out in two cities in southern Rio Grande do Sul, Brazil, aims to get understand how people with chronic Chagas disease live in order to draw possible nursing actions towards a healthier life. The study has a descriptive and exploratory character with a qualitative approach. Data were collected through semi-sctructured interviews carried out with ten Chagas disease chronic carriers at their houses. The results showed that the sickness symptomatology did not appear in the acute phase of the disease; it also showed that most of the carriers make use of palliative medication to alleviate symptoms. There are great limitations to their performing daily chores, especially for heart-affected carriers. The support of the health team, especially the nurse's, is valuable to the clinical management of the patient. When it is started in the early stages of the disease, a better quality of life and a longer life expectancy can be reached.

Evidence of Chagas disease in seronegative Brazilian patients with megaesophagus

BACKGROUND

After 100 years of research, Chagas disease (CD) remains an important public health problem in Latin America. The symptomatic chronic phase is usually characterized by cardiac or digestive involvement and diagnosis currently relies on the measurement of Trypanosoma cruzi-specific antibodies produced in response to the infection. However, the detection of parasite DNA in seronegative persons has been reported.

METHODS

The prevalence of CD in a population with esophageal disorders was assessed by conventional serology. We also detected T. cruzi DNA in blood samples of seronegative and inconclusive patients by nested polymerase chain reaction (N-PCR).

RESULTS

The seroprevalence of CD determined by conventional serologic tests (indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA)) was 79% in 513 patients with esophageal disorders. Out of 41 blood samples, N-PCR was positive in 31 (76%) cases for which serology was negative or inconclusive.

CONCLUSIONS

As all patients presented with clinical signs suggestive of the digestive form of CD and most of them were born in endemic areas, we highlight the importance of improving diagnosis of the disease and the implications for blood bank screening. Our data suggest that N-PCR is effective in the detection of T. cruzi DNA in patients with inconclusive or negative serology, and it may eventually be useful in the determination of the etiology of megaesophagus.