Laparoscopic diagnosis of pleural mesothelioma presenting with pseudoachalasia

Is it necessary to perform a morphological assessment for an esophageal motility disorder? A retrospective descriptive study

BACKGROUND

Esophageal motility disorders are most often of primary origin but may be secondary to an occult malignancy or another etiology. High-resolution esophageal manometry cannot differentiate between secondary or primary origin. This study aimed at discussing the usefulness of a morphological assessment in the diagnosis of specific esophageal motility disorders, and to establish the predictive factors of a potential secondary origin.

METHODS

In this retrospective study, patients with suspected esophageal motility disorders who underwent an esophageal manometry were included. High-resolution manometry results were interpreted according to the Chicago Classification, 3rd version. The results of endoscopic ultrasound and computed tomography, assessed by a panel of experts, allowed to diagnose a secondary origin.

KEY RESULTS

Out of 2138 patients undergoing manometry, 502 patients had a esophageal motility disorder suspect to be from secondary origin; among them 182 patients underwent tomography or endoscopic ultrasound. According to experts, 16 patients (8.8%) had a secondary esophageal motility disorder: esophagogastric junction outflow obstruction (n = 7), jackhammer disorder (n = 4), achalasia (n = 3) and localized pressurization (n = 2). The etiology was malignant in 8 patients. Predictive factors suggesting potential secondary esophageal motility disorders were smoking, age ≥ 58 years and an Integrated Relaxation Pressure higher than 10 mmHg for water swallows.

CONCLUSION AND INFERENCES

Esophageal motility disorders with organic origin are not uncommon. A morphological assessment using endoscopic ultrasonography and/or computed tomography may be of use to diagnose a secondary origin, especially in the elderly and smokers.

Pseudoachalasia: a diagnostic challenge. When to consider and how to manage?

Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.

Duration of symptoms and manometric parameters offer clues to diagnosis of pseudoachalasia

BACKGROUND

Pseudoachalasia manifests high-resolution manometry (HRM) findings of achalasia but results from a secondary process. We analyzed clinical and HRM characteristics of pseudoachalasia, including malignant and non-malignant subtypes.

METHODS

High-resolution manometry was retrospectively reviewed in patients with confirmed pseudoachalasia, and corroborated with endoscopic and radiographic studies. A control cohort of idiopathic achalasia patients was identified. Clinical characteristics, Eckardt score, and HRM metrics were extracted from institutional records. Grouped data and medians (interquartile range) were compared between pseudoachalasia and idiopathic achalasia, and between malignant and non-malignant pseudoachalasia, using parametric and non-parametric statistical tests.

KEY RESULTS

Of 28 pseudoachalasia patients (62.2 ± 2.5 years, 60.7% female), 18 (64.3%) had malignancy, and 10 (35.7%) had non-malignant obstruction. Although Eckardt score did not differentiate pseudoachalasia from 58 achalasia patients (55.9 ± 2.5 years, 53.4% female), weight loss was greater (median 9.1 [5.0-18.5] vs 3.6 [0-9.1] kg, P < .02) with shorter duration of symptoms (median 12.9 [8.0-38.6] vs 36.0 [25.7-45.0] weeks, P < .001] in pseudoachalasia. Esophagogastric junction (EGJ) metrics demonstrated lower mean IRP values and lower EGJ contractile integral in pseudoachalasia (P < .04 for each comparison with idiopathic achalasia). Type 1 pattern was more frequent in pseudoachalasia (39.3% vs 13.8%, P < .008). Pseudoachalasia demonstrated incomplete HRM patterns, with lower rates of lack of peristalsis (79.6%, vs 93.1% in achalasia, P < .05). Despite higher Eckardt scores in malignant vs non-malignant pseudoachalasia (median 8.0 [7.0-9.0] vs 6.0 [3.5-7.8], P < .03], no significant HRM differences were noted.

CONCLUSIONS AND INFERENCES

Pseudoachalasia manifests with a shorter history, greater weight loss, and incomplete HRM achalasia patterns compared to achalasia.

Pseudoachalasia: a diagnostic challenge

Here, we present a case of a 78-year-old man that underwent gastrointestinal endoscopy because of one- month history of dysphagia to liquids and solid foods with accompanying weight loss. On endoscopy, there was distal esophageal stenosis. Multiple biopsies were obtained. Histologic examination of the samples revealed normal tissue. The stenosis was treated by dilatation and abdomino pelvic computed tomography scanning was performed to search for an underlying malignant lesion that showed a mass adjacent to distal esophagus. We did endosonography- guided fine needle aspiration of the mass. It was a squamous cell carcinoma (SCC). Malignancy is a challenging diagnosis in patients with dysphagia and near normal endoscopy. To our knowledge, there are a few reports of SCC to cause it.

Endoscope-guided pneumatic dilation for treatment of esophageal achalasia

Pneumatic dilation (PD) is considered to be the first line nonsurgical therapy for achalasia. The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force. The endoscope-guided procedure is done without fluoroscopic control. Clinicians usually use a low-compliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia. It has the advantage of determining mucosal injury during the dilation process, so that a repeat endoscopy is not needed to assess the mucosal tearing. Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities. Although the results may be promising, long-term follow-up is required in the near future.