1
|
Subedi D, Parajuli BR, Bista N, Rauniyar S, Dhonju K, Bhusal S, Aryal E, Adhikari D, Aryal S, Karna A. Achalasia cardia: A case report in young female. Clin Case Rep 2024; 12:e9239. [PMID: 39104735 PMCID: PMC11298990 DOI: 10.1002/ccr3.9239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/18/2024] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Key Clinical Message This case emphasizes the need for early recognition and accurate diagnosis of achalasia in young adults to avoid exacerbation of the condition and misdiagnosis as GERD. Patient outcomes and quality of life are greatly enhanced by suitable diagnostic techniques, appropriate therapy, interdisciplinary care, and comprehensive patient education along with frequent follow-ups. Abstract Achalasia results from the degeneration of inhibitory ganglion cells within the esophageal myenteric plexus and the lower esophageal sphincter (LES), leading to a loss of inhibitory neurons and resulting in the absence of peristalsis with failure of LES relaxation. Its origins are multifactorial, potentially involving infections, autoimmune responses, and genetics, with equal incidence in males and females. The hallmark symptoms include progressive dysphagia for solids and liquids, along with regurgitation, heartburn, and non-cardiac chest pain. A 22-year-old female patient initially diagnosed with gastroesophageal reflux disease (GERD) received proton pump inhibitors and antacid gel for persistent dysphagia and regurgitation. Subsequent tests including barium esophagogram and manometry indicated Type II Achalasia Cardia. The patient showed clinical improvement with relief of dysphagia, regurgitation, and heartburn symptoms after pneumatic balloon dilatation (PBD). She was advised to follow up after 6 months with upper gastrointestinal (UGI) endoscopy and manometry in the outpatient clinic for regular endoscopic surveillance as there is a risk of transformation to esophageal carcinoma. Diagnosing achalasia in young adults poses challenges due to its diverse presentation and resemblance to other esophageal disorders like GERD. Diagnosis relies on clinical symptoms and imaging studies such as barium esophagogram revealing a bird's beak appearance and esophageal manometry showing absent peristalsis. UGI endoscopy is needed to rule out malignancy. Treatment options include non-surgical approaches like medication and Botox injections, as well as surgical methods such as pneumatic balloon dilation, laparoscopic Heller myotomy, and per-oral endoscopic myotomy (POEM). The treatment options depend upon the patient's condition at presentation and their individual choices. This case report emphasizes that it is crucial to consider achalasia as a potential differential diagnosis in young adults with dysphagia, especially if conventional treatments for acid peptic disorder do not alleviate symptoms. Prompt diagnosis and appropriate management can lead to significant clinical improvement and better patient outcomes.
Collapse
Affiliation(s)
- Deepak Subedi
- Nepalese Army Institute of Health Sciences College of MedicineKathmanduNepal
| | | | - Neha Bista
- Chitwan Medical College and Teaching HospitalChitwanNepal
| | | | - Kiran Dhonju
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | | | - Egesh Aryal
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | | | | | - Ayush Karna
- Kathmandu University School of Medical SciencesDhulikhelNepal
| |
Collapse
|
2
|
Rodriguez DN, Gera K, Paudel B, Pham A. Wernicke's Encephalopathy in Type 2 Achalasia: Case Report and Literature Review. J Investig Med High Impact Case Rep 2023; 11:23247096231190628. [PMID: 37539958 PMCID: PMC10403980 DOI: 10.1177/23247096231190628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/07/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
Achalasia is primarily a smooth muscle motility disorder of the esophagus driven by aberrant peristalsis and failure of sphincter relaxation. Notably, achalasia is a heterogeneous disease with primarily 3 possible pattern subtypes. According to the review of current cases and literature regarding achalasia, patients primarily present with dysphagia, usually to solids and, if progressed, to solids and liquids. Rarely, untreated achalasia may result in thiamine deficiency and present as Wernicke-Korsakoff syndrome (WKS). This acute neurologic condition primarily affects the central and peripheral nervous system and is known by the triad of ataxia, ophthalmoplegia, and confusion. Individuals who present with WKS typically have a notable history of chronic alcohol abuse with decreased thiamine intake and metabolism. Although less common, individuals with WKS may have a pertinent history of starvation, anorexia nervosa, and malnutrition. This case highlights a unique presentation of Wernicke's encephalopathy (WE) in a 30-year-old woman with severe type II achalasia complicated by a 60-pound weight loss in a span of 2 months. According to our literature review, there have only been 2 previously reported cases of severe achalasia leading to the development of WE. Considering the limited number of case reports available, WE must be in the differentials in patients with underlying achalasia, and our case report highlights this unusual presentation with corresponding brain imaging and manometry testing.
Collapse
|
3
|
Endoscopic Balloon Dilation Versus Laparoscopic Heller Myotomy: Comparing Two Treatment Methods for Achalasia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03521-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
|
4
|
GHOLIPOUR M, MIKAELI J, MOWLA SJ, BAKHTIARIZADEH MR, SAGHAEIAN JAZI M, JAVID N, FAZLOLLAHI N, KHOSHNIA M, BEHNAMPOUR N, MORADI A. Identification of differentially expressed microRNAs in primary esophageal achalasia by next-generation sequencing. Turk J Biol 2021; 45:262-274. [PMID: 34377051 PMCID: PMC8313935 DOI: 10.3906/biy-2101-61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022] Open
Abstract
Molecular knowledge regarding the primary esophageal achalasia is essential for the early diagnosis and treatment of this neurodegenerative motility disorder. Therefore, there is a need to find the main microRNAs (miRNAs) contributing to the mechanisms of achalasia. This study was conducted to determine some patterns of deregulated miRNAs in achalasia. This case-control study was performed on 52 patients with achalasia and 50 nonachalasia controls. The miRNA expression profiling was conducted on the esophageal tissue samples using the next-generation sequencing (NGS). Differential expression of miRNAs was analyzed by the edgeR software. The selected dysregulated miRNAs were additionally confirmed using the quantitative reverse transcription polymerase chain reaction (qRT-PCR). Fifteen miRNAs were identified that were significantly altered in the tissues of the patients with achalasia. Among them, three miRNAs including miR-133a-5p, miR-143-3p, and miR-6507-5p were upregulated. Also, six miRNAs including miR-215-5p, miR-216a-5p, miR-216b-5p, miR-217, miR-7641 and miR-194-5p were downregulated significantly. The predicted targets for the dysregulated miRNAs showed significant disease-associated pathways like neuronal cell apoptosis, neuromuscular balance, nerve growth factor signaling, and immune response regulation. Further analysis using qRT-PCR showed significant down-regulation of hsa-miR-217 (p-value = 0.004) in achalasia tissue. Our results may serve as a basis for more future functional studies to investigate the role of candidate miRNAs in the etiology of achalasia and their application in the diagnosis and probably treatment of the disease.
Collapse
Affiliation(s)
- Mahin GHOLIPOUR
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, GorganIran
| | - Javad MIKAELI
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, TehranIran
| | - Seyed Javad MOWLA
- Department of Genetics, Faculty of Biological Sciences, Tarbiat Modares University, TehranIran
| | | | - Marie SAGHAEIAN JAZI
- Metabolic Disorders Research Center, Golestan University of Medical Sciences, GorganIran
| | - Naeme JAVID
- Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, GorganIran
| | - Narges FAZLOLLAHI
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, TehranIran
| | - Masoud KHOSHNIA
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, GorganIran
| | - Naser BEHNAMPOUR
- Department of Biostatistics, Faculty of Health, Golestan University of Medical Sciences, GorganIran
| | - Abdolvahab MORADI
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, GorganIran
- Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, GorganIran
| |
Collapse
|
5
|
Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci 2020; 65:38-65. [PMID: 31451984 DOI: 10.1007/s10620-019-05784-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023]
Abstract
AIM To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy. METHODS Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria. RESULTS Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM. CONCLUSION This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.
Collapse
Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY, 11501, USA
| |
Collapse
|
6
|
Nickel F, Müller PC, de la Garza JR, Tapking C, Benner L, Fischer L, Steinemann DC, Rupp C, Linke GR, Müller-Stich BP. Heller myotomy versus endoscopic balloon dilatation for achalasia: A single center experience. Medicine (Baltimore) 2019; 98:e17714. [PMID: 31689807 PMCID: PMC6946323 DOI: 10.1097/md.0000000000017714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/24/2019] [Accepted: 09/28/2019] [Indexed: 01/09/2023] Open
Abstract
This study aimed to compare clinical results, symptom relief, quality of life and patient satisfaction after the 2 most common procedures for achalasia treatment: laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (EBD).Patients treated at University Hospital of Heidelberg with LHM or EBD were included. A retrospective chart review of perioperative data and a prospective follow-up of therapeutic efficiency, Gastrointestinal Quality of Life Index (GIQLI) and patient satisfaction was conducted.Follow-up data (mean follow-up: 75.1 ± 53.9 months for LHM group and 78.9 ± 45.6 months for EBD) were obtained from 36 patients (19 LHM; 17 EBD). Eckardt score (median (q1,q3): 2 (1,4) in both groups, P = .91, GIQLI (LHM: 117 (91.5, 126) vs EBD: 120 (116, 128), P = .495) and patient satisfaction (3 (2,3) vs 3 (2,4), P = .883) did not differ between groups. Fifteen patients (78.9%) in LHM group and 11 (64.7%) in EBD group (P = .562) stated they would undergo the intervention again. All patients with EBD had at least 2 dilatations (100%), whilst only 2 patients (10.5%) had dilatation after LHM (P < .001). There were no complications after EBD, but 2 after LHM (10.5%, P = .517).Both LHM and EBD are able to control symptoms and provide similar quality of life and patient satisfaction. However, reintervention rate was higher following EBD, hence LHM provided a more sustained treatment than EBD.
Collapse
Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Transplant Surgery
| | | | | | | | - Laura Benner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg
| | - Lars Fischer
- Department of Surgery, Hospital Mittelbaden, Balger Strasse 50, 76532 Baden-Baden, Germany
| | - Daniel C. Steinemann
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Christian Rupp
- Department of Internal Medicine, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Georg R. Linke
- Department of Surgery, Hospital STS Thun AG, Krankenhausstrasse 12, 3600 Thun, Switzerland
| | | |
Collapse
|
7
|
Lehmann S, Ferrie S, Carey S. Nutrition Management in Patients With Chronic Gastrointestinal Motility Disorders: A Systematic Literature Review. Nutr Clin Pract 2019; 35:219-230. [PMID: 30989698 DOI: 10.1002/ncp.10273] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions. METHODS A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included. RESULTS Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates. CONCLUSION Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis.
Collapse
Affiliation(s)
- Sara Lehmann
- University of Sydney, School of Life and Environmental Sciences, Sydney, Australia
| | - Suzie Ferrie
- University of Sydney, School of Life and Environmental Sciences, Sydney, Australia.,Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sharon Carey
- University of Sydney, School of Life and Environmental Sciences, Sydney, Australia.,Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
8
|
Abbas AM, Medani S, Abdallah TM, Gasim GI. Clinical Utility of Esophageal manometry in the patients with dysphagia - Experience from Sudan. Int J Health Sci (Qassim) 2016; 10:522-531. [PMID: 27833517 PMCID: PMC5085347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVES The aim of this study was to assess the clinical utility of esophageal manometry among Sudanese patients presenting to the National Centre for Gastrointestinal and Liver Diseases, Ibn Sina Hospital, Khartoum, Sudan. METHODOLOGY Consecutive patients referred for esophageal manometry at the aforementioned center from July 2008 through January 2011 were included in the study. Manometric studies were done after stopping medicines with a known effect on esophageal motility and an overnight fast. Immediately before the manometric study, the patients' history and clinical examination were recorded using a structured questionnaire. RESULTS The major referral reason was the investigation of dysphagia in 78 patients (60.5%), followed by the evaluation of Gastroesophageal reflux disease (GERD) in 39 patients (30%), while 11 patients (9%) were referred because of non-cardiac chest pain. The manometric diagnosis in the 78 patients with dysphagia, where 51(65.4%) had achalasia, 13(16.7%) had nonspecific motility disorder, the remaining percentage was formed by GERD diffuse esophageal spasm, connective tissue disease, Nutcracker esophagus, hypertensive lower esophageal sphincter, patient manometry suggestive of myasthenia gravis, and normal manometry. CONCLUSION GERD and Achalasia were the commonest conditions among the study group. Patients presenting with achalasia manifest the same clinical symptoms as published in the literature. The leading abnormality predisposing to GERD was hypotensive lower esophageal sphincter and weak esophageal clearance function. GERD was main cause of non-cardiac chest pain in the study population. However, it is difficult to generalize the findings of this study for the whole country since it was a single center study.
Collapse
Affiliation(s)
- Amin M Abbas
- National Centre for Gastrointestinal and Liver Disease, Ibn Sina Specialized Hospital, Alamarat, Saudi Arabia
| | - Sami Medani
- National Centre for Gastrointestinal and Liver Disease, Ibn Sina Specialized Hospital, Alamarat, Saudi Arabia
| | - Tajeldin M Abdallah
- Department of Medicine, Faculty of Medicine, Kassala University, Sudan, Saudi Arabia
| | - Gasim I Gasim
- Qassim College of Medicine, Qassim University, Buraydah, Saudi Arabia
| |
Collapse
|
9
|
Abstract
BACKGROUND Achalasia is extremely rare in infants. CASE CHARACTERISTICS We report three infants of age 9, 7 and 12 months, who presented with recurrent non-bilious vomiting, repeated chest infection and severe failure to thrive. Diagnosis of achalasia cardia was confirmed on contrast-swallow study. Hellers cardiomyotomy with fundoplication led to complete symptomatic relief, and weight-gain on follow-up. MESSAGE Achalasia cardia is often misdiagnosed as gastroesophageal reflux disease which leads to significant delay in diagnosis and increased morbidity.
Collapse
Affiliation(s)
- Rupa Banerjee
- Departments of Pediatric Surgery and *Pediatric Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India. Correspondence to: Dr Alpana Prasad, Room no 1284, Pediatric Surgery office (2nd floor), Department of Pediatric Surgery, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi 110 060,
| | | | | | | |
Collapse
|
10
|
Brodie A, Okeahialam N, Farinella E. Unusual case of respiratory embarrassment secondary to tracheal compression by a dilated oesophagus in a patient with recurrent achalasia. BMJ Case Rep 2016; 2016:bcr-2016-215247. [PMID: 27147631 DOI: 10.1136/bcr-2016-215247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 79-year-old woman with recurrent achalasia following a laparoscopic Heller's cardiomyotomy. The patient presented to the emergency department, with epigastric pain, severe dyspnoea and profound respiratory acidosis. She required intubation and ventilation followed by gastric decompression with nasogastric tube and the administration of intravenous antibiotics for a lower respiratory tract infection. Once stable, she underwent a CT scan revealing a massively dilated oesophagus causing marked tracheal compression. She received a period of continuous positive airway pressure ventilation while on the intensive care unit, for persistent low saturations, however, this was promptly ceased due to exacerbation of gastric dilation and fears over perforation. The patient responded well to conservative measures and was discharged home 18 days later awaiting follow-up with operating consultant surgeon.
Collapse
Affiliation(s)
- Andrew Brodie
- Department of Urology, Lister Hospital, Stevenage, Hertfordshire, UK
| | | | | |
Collapse
|
11
|
Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther 2015; 6:145-55. [PMID: 26558149 PMCID: PMC4635155 DOI: 10.4292/wjgpt.v6.i4.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/06/2015] [Accepted: 10/16/2015] [Indexed: 02/06/2023] Open
Abstract
This article reviews currently available pharmacological options available for the treatment of achalasia, with a special focus on the role of botulinum toxin (BT) injection due to its superior therapeutic effect and side effect profile. The discussion on BT includes the role of different BT serotypes, better pharmacological formulations, improved BT injection techniques, the use of sprouting inhibitors, designer recombinant BT formulations and alternative substances used in endoscopic injections. The large body of ongoing research into achalasia and BT may provide a stronger role for BT injection as a form of minimally invasive, cost effective and efficacious form of therapy for patients with achalasia. The article also explores current issues and future research avenues that may prove beneficial in improving the efficacy of pharmacological treatment approaches in patients with achalasia.
Collapse
|
12
|
|
13
|
Abstract
Achalasia is a primary esophageal motility disorder, which shows distinct clinical, manometric, radiologic, and pathologic features. Available treatment strategies are pharmacological, endoscopic or surgical. In the past decades preferred treatment has alternated between surgical myotomy (presently Laparoscopic Heller Myotomy [LHM]) and endoscopic balloon dilation (EBD). While surgical myotomy promises superior long-term results and significantly less retreatment, endoscopic balloon dilation is initially far less invasive and yields comparable results after redilation. Peroral Endoscopic Myotomy (POEM) aims to combine the minimal invasive approach through the mouth with the better long-term results after LHM. Initial findings in the literature point to comparable success-rates after POEM and LHM. In the literature complication rates are similar to those obtained after surgery. This new interventional technique should be subject to randomized controlled trials and compared to EBD and LHM.
Collapse
Affiliation(s)
- Markus Bo Schoenberg
- Uniklinikum Großhadern, Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Marchioninistraße 15 D-81377 München, Munich, Germany
| | | | | |
Collapse
|
14
|
Pang J, Borjeson TM, Muthupalani S, Ducore RM, Carr CA, Feng Y, Sullivan MP, Cristofaro V, Luo J, Lindstrom JM, Fox JG. Megaesophagus in a line of transgenic rats: a model of achalasia. Vet Pathol 2014; 51:1187-200. [PMID: 24457157 DOI: 10.1177/0300985813519136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Megaesophagus is defined as the abnormal enlargement or dilatation of the esophagus, characterized by a lack of normal contraction of the esophageal walls. This is called achalasia when associated with reduced or no relaxation of the lower esophageal sphincter (LES). To date, there are few naturally occurring models for this disease. A colony of transgenic (Pvrl3-Cre) rats presented with megaesophagus at 3 to 4 months of age; further breeding studies revealed a prevalence of 90% of transgene-positive animals having megaesophagus. Affected rats could be maintained on a total liquid diet long term and were shown to display the classic features of dilated esophagus, closed lower esophageal sphincter, and abnormal contractions on contrast radiography and fluoroscopy. Histologically, the findings of muscle degeneration, inflammation, and a reduced number of myenteric ganglia in the esophagus combined with ultrastructural lesions of muscle fiber disarray and mitochondrial changes in the striated muscle of these animals closely mimic that seen in the human condition. Muscle contractile studies looking at the response of the lower esophageal sphincter and fundus to electrical field stimulation, sodium nitroprusside, and L-nitro-L-arginine methyl ester also demonstrate the similarity between megaesophagus in the transgenic rats and patients with achalasia. No primary cause for megaesophagus was found, but the close parallel to the human form of the disease, as well as ease of care and manipulation of these rats, makes this a suitable model to better understand the etiology of achalasia as well as study new management and treatment options for this incurable condition.
Collapse
Affiliation(s)
- J Pang
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - T M Borjeson
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - S Muthupalani
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - R M Ducore
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - C A Carr
- The Picower Institute for Learning and Memory, RIKEN-MIT Center for Neural Circuit Genetics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Y Feng
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - M P Sullivan
- VA Boston Healthcare System, Harvard Medical School, West Roxbury, MA, USA
| | - V Cristofaro
- VA Boston Healthcare System, Harvard Medical School, West Roxbury, MA, USA
| | - J Luo
- Department of Neuroscience, Medical School of the University of Pennsylvania, Philadelphia, PA, USA
| | - J M Lindstrom
- Department of Neuroscience, Medical School of the University of Pennsylvania, Philadelphia, PA, USA
| | - J G Fox
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| |
Collapse
|
15
|
Müller M, Eckardt AJ, Wehrmann T. Endoscopic approach to achalasia. World J Gastrointest Endosc 2013; 5:379-390. [PMID: 23951393 PMCID: PMC3742703 DOI: 10.4253/wjge.v5.i8.379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 05/10/2013] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW Botulinum toxin injection into the lower esophageal sphincter is an established therapy for the treatment of achalasia. This review will highlight recent studies that shed light on the role of Botulinum toxin injection in the management of achalasia. RECENT FINDINGS Recent studies have shown that Botulinum toxin injection is the most common initial endoscopic therapy for achalasia, most likely due to its safety and ease of administration. However, this trend represents a deviation from recent guidelines which consider Botulinum toxin injection less efficacious than alternative treatments like pneumatic dilation and laparoscopic Heller myotomy. Over the past decade, multiple commercial formulations of Botulinum toxin injection have been introduced, but the techniques, indications, and therapeutic efficacy for Botulinum toxin have largely remained unchanged. This review will evaluate recent guidelines, consensus articles, meta-analyses, and landmark studies to expound on the short and long-term efficacy of Botulinum toxin, injection dosages, and technique, as well as its efficacy compared to pneumatic dilation, myotomy, and combination therapy. SUMMARY Despite its relatively poor long-term efficacy, Botulinum toxin injection continues to play an important role in elderly patients with comorbidities and as salvage therapy for achalasia.
Collapse
|
17
|
Cattelan F, Barlotta A, Berardi M, Carraro S, Baraldi E, Costantini M, Giorgi B. Case 1: An adolescent with chronic cough and wheezing. Paediatr Child Health 2013; 18:137-9. [DOI: 10.1093/pch/18.3.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2012] [Indexed: 11/13/2022] Open
|
18
|
A case of achalasia presented with cardiopulmonary arrest. Case Rep Surg 2013; 2012:794858. [PMID: 23326747 PMCID: PMC3540645 DOI: 10.1155/2012/794858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/11/2012] [Indexed: 11/17/2022] Open
Abstract
Achalasia is a rare disorder characterised by obstruction of the distal oesophagus and subsequent dilation of the proximal oesophagus. Patients generally complain of gastrointestinal symptoms; however, pulmonary symptoms and complications may also occur. A 35-year-old woman was brought to our emergency service complaining of sudden-onset dyspnea that started 15 minutes earlier during dinner. She suffered a cardiopulmonary arrest due to aspiration 5 minutes after being admitted to the emergency room and was intubated. Thoracic computed tomography examination showed that her oesophagus was filled with undigested food. Heller cardiomyotomy and Dor fundoplication was performed via laparotomy with the diagnosis of primary achalasia, and she was discharged as uneventful on the 5th postoperative day.
Collapse
|
19
|
Mc Cormack O, Timlin M, Mc Gowan A, Healy ML, Ravi N, Reynolds JV. Management of squamous cell cancer of the oesophagus in a patient with a polyglandular endocrinopathy (APECED) and achalasia. J Gastrointest Surg 2012; 16:1963-6. [PMID: 22476927 DOI: 10.1007/s11605-012-1879-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 03/20/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION We report a case of a 37-year-old man, with a background of a rare polyglandular autoimmune syndrome and achalasia, who developed an oesophageal tumour. Both autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) or type I polyglandular syndrome and achalasia confer increased risk of development of oesophageal squamous cell carcinoma. METHODS Despite having had multiple endoscopic examinations and dilatations in the recent past, this patient presented with dysphagia, and on endoscopy, he was found to have a mid-oesophageal tumour. A multidisciplinary team approach was vital in his management as careful monitoring of underlying disorders including Addison's disease and hypoparathyroidism were challenging during neoadjuvant chemoradiotherapy and in the perioperative period. RESULTS He made an uneventful recovery after a three-stage oesophagectomy, and histologically, he had a complete pathological response. CONCLUSION To our knowledge, this is the first successful outcome of a patient with APECED and oesophageal carcinoma in the literature.
Collapse
Affiliation(s)
- Orla Mc Cormack
- Department of Surgery, St. James's Hospital, Dublin, and Trinity College Dublin, Dublin, Ireland.
| | | | | | | | | | | |
Collapse
|