Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

AIM

To investigate the behavior of pulsatile pressure zones (PPZ’s) as noted on high resolution esophageal impedance manometry (HREIM), and determine their association with dysphagia.

METHODS

Retrospective, single center case control design screening HREIM studies for cases (dysphagia) and controls (no dysphagia). Thoracic radiology studies were reviewed further in cases for (thoracic cardiovascular) thoracic cardiovascular (TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function (impedance).

RESULTS

Among 317 screened patients, 56% cases and 64% controls had PPZ’s. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ’s in these 50 cases and 59 controls was similar (average 1.4 PPZ/patient). Controls (mean 31.2 ± SD 12 years) were a significantly younger population than cases (mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls (15.7 ± 10.0 mmHg) than cases (10.8 ± 9.7 mmHg). Although statistically significant (P = 0.005), it was a weak predictor using logistic regression and ROC model (AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology (1 aberrant subclavian artery, 2 dilated left atrium). The posture (supine vs upright) with more prominent PPZ’s impaired bolus clearance in 9 additional cases by > 20%.

CONCLUSION

Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Tofacitinib for the treatment of tumor necrosis factor-α inhibitor refractory esophageal Crohn's disease: a case report

BACKGROUND

Esophageal Crohn's disease is reported as a rare manifestation, although its prevalence may be underestimated because upper endoscopies are not routinely performed in asymptomatic adults. Tofacitinib, an oral janus kinase inhibitor, is a new biologic that has shown promise in the treatment of ulcerative colitis and may be effective in the treatment of Crohn's disease according to phase 2 trials. We report the first case of esophageal Crohn's disease successfully treated with tofacitinib in a patient with worsening symptoms despite maintenance therapy with a tumor necrosis factor-α inhibitor.

CASE PRESENTATION

A 67-year-old Caucasian woman presented with new dysphagia and had findings of esophageal Crohn's disease on endoscopy. The dosage of her current biologic therapy-adalimumab-was increased in frequency, without improvement. Our patient was started on tofacitinib and demonstrated an improvement in symptoms, with a repeat endoscopy showing resolution of the previous lesions.

CONCLUSION

Esophageal Crohn's disease is likely underdiagnosed but is an important consideration in a patient with new symptoms of dysphagia and known Crohn's disease. Tofacitinib, while a novel agent, could have a role in the treatment of esophageal Crohn's disease that does not improve with intensification of the current biologic therapy. It provides a different mechanism in patients who become refractory to maintenance therapy.

Impact of race on colorectal cancer

BACKGROUND

Several studies have shown that colorectal cancer runs a more severe course in blacks compared with whites. Black patients tend to have more advanced disease at diagnosis and are more likely to die of cancer than are white patients. The present study was carried out to compare the characteristics and outcomes of colon cancer in blacks and whites in a Veterans Affairs Medical Center, where patients are expected to receive similar treatment irrespective of race.

METHODS

The database of the Veterans Affairs Medical Center was searched for all patients with a histologic diagnosis of colon cancer diagnosed since 1996. Detailed information on patient and tumor characteristics was obtained. In addition the type of treatment and outcome was analyzed.

RESULTS

A total of 300 subjects were included in the study. They comprised 205 white and 95 black patients. There was no difference in age at presentation between the 2 groups. Blacks were more likely to have anemia (P = .005) and rectal bleeding (P < .001) than were whites. However there was no difference between the 2 groups with respect to the histologic grade of the tumor, the extent of disease at presentation, the proportion of patients receiving curative surgery, and the time to death after diagnosis.

CONCLUSIONS

There was no racial difference in the treatment outcome of colon cancer in patients treated at a Veterans Affairs Medical Center. These findings indicate that if patients receive similar treatment, the racial background of an individual does not have any impact on the severity of disease at presentation and the outcome of treatment.