Hematological indices as indicators of silent inflammation in achalasia patients: A cross-sectional study

Complete blood count (CBC)-derived parameters such as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), eosinophil-to-lymphocyte (ELR) ratio, and platelet-to-lymphocyte ratio (PLR) are sensitive markers of occult inflammation and disease activity for systemic lupus erythematosus, rheumatoid arthritis, psoriasis, esophageal cancer, etc. We assessed NLR, PLR, MLR, and ELR as indicators of inflammation in achalasia patients.This cross-sectional study included 103 achalasia patients and 500 healthy blood donor volunteers (HD). Demographic, clinical and laboratory information was collected. NLR, MLR, ELR and PLR were calculated. Peripheral Th22, Th17, Th2 and Th1 subsets were determined by flow cytometry. Correlation between hematologic indices and clinical questionnaires scores, HRM parameters and CD4+ T-cells were assessed. Hematologic parameters associated with the different achalasia subtypes were evaluated by logistic regression analysis.Hemoglobin, leukocytes, lymphocytes, monocytes, and platelets counts were significantly lower in achalasia patients vs controls. NLR (P = .006) and ELR (P < .05) were higher in achalasia patients vs controls. NLR was significantly associated with achalasia in multivariate analysis (P < .001). Compared to HD, the achalasia group was 1.804 times more likely to have higher NLR (95% CI 1.287-2.59; P < .001). GERD-HRQL score had statistically significant correlations with PLR (Pearson's rho:0.318, P = .003), and ELR (Pearson's rho:0.216; P = .044). No correlation between CD4+ T-cells and hematologic indices were determined. NLR with a cut-off value of ≥2.20 and area under the curve of 0.581 yielded a specificity of 80% and sensitivity of 40%, for the diagnosis of achalasia.NLR is increased in achalasia patients vs HD. Sensitivity and specificity achieved by NLR may contribute to a clinical and manometric evaluation. We suggest these indices as potential indicators of silent inflammation and disease activity.

Allgrove syndrome: case report of 7 years old boy from Bahawalpur

Allgrove syndrome is a rare autosomal recessive syndrome of unknown prevalence. The first case of Allgrove syndrome was reported in 1978 by Allgrove. It is characterized by triad of achalasia, alacrima and adrenal hypoplasia. There are also associated autonomic and neurological manifestations. We report the case of a 7 years old boy being treated for achalasia cardia, presented with fits and altered sensorium which on further investigations was found to be due to adrenal insensitivity (Raised ACTH level, low Cortisol level, and normal Aldosterone and Renin ratio). He also had undiagnosed alacrima since birth, mild degree of hearing loss and autonomic instability in the form of episodic hypertension.

Expression and significance of interleukin-17 and interleukin-22 in the serum and the lower esophageal sphincter of patients with achalasia

Background/Aim

: We studied the expression of interleukin-17 and interleukin-22 in the serum and the lower esophageal sphincter (LES) in healthy individuals and in patients diagnosed with achalasia (AC) to gain a better understanding of the etiopathogenesis of AC.

Patients and Methods

Our study comprised 14 randomly selected patients with AC who underwent peroral endoscopic myotomy and 14 randomly selected healthy individuals who served as controls. Venous blood samples were evaluated in all study subjects to detect the expression of interleukin-17 and interleukin-22 in the serum using an enzyme-linked immunosorbent assay. Immunohistochemistry studies were performed to evaluate LES myofilaments obtained from both groups, as well as from 12 patients diagnosed with a subendothelial non-invasive tumor and who had undergone submucosal tunneling endoscopic resection, to assess the expression of interleukin-17 and interleukin-22 in LES myofilaments.

Results

Compared with that in the control group, the expression of interleukin-17 and interleukin-22 in the serum and LES, in patients with AC, was significantly increased and was positively correlated.

Conclusion

Interleukin-17 and interleukin-22 are upregulated in the serum and LES in patients with AC, suggesting that both interleukin-17 and interleukin-22 are involved in the pathogenesis of AC, and that AC may be an immune-mediated inflammatory disease.

Allgrove Syndrome: Adrenal Insufficiency with Hypertensive Encephalopathy

Allgrove syndrome or triple-Asyndrome is a rare familial multisystem autosomal recessive disorder. It is characterised by triad of alacrima, achalasia and adrenal insufficiency due to adrenocorticotropin hormone (ACTH) resistance. If it is associated with autonomic dysfunction, it is termed as 4-Asyndrome. This syndrome is caused by a mutation in the Achalasia - Addisonism - Alacrima (AAAS) gene on chromosome 12q13 encoding the nuclear pore protein ALADIN. A5-year boy presented with history of fits and altered sensorium for one day. He also had increased pigmentation of body and persistent vomiting since six months of age. Laboratory investigations and imaging revealed alacrimia, achalasia and adrenal insufficiency due to ACTH resistance. He had episodes of hypertensive crises, for which he was thoroughly investigated and it was found to be due to autonomic instability. Based on clinical findings and investigations he was diagnosed as case of Allgrove syndrome or 4-Asyndrome with autonomic dysfunction.

Allgrove syndrome

Allgrove syndrome is a rare autosomal recessive disorder. It is also known as the 3A syndrome and characterised by the triad of achalasia, alacrima and adrenal insufficiency. The AAAS gene is encoded on chromosome 12q13. We report the case of a 23-year-old woman who presented at the hospital with adrenal crisis that was triggered by infection of the urinary system and gastrointestinal bleeding. She had a known diagnosis of achalasia for eight years, and ophthalmologic examination revealed alacrima. Based on our findings, the patient was diagnosed with Allgrove syndrome.

Novel mechanism for impaired nitrergic relaxation in achalasia

New insights into the pathogenesis of achalasia indicate that incubation with serum from patients with achalasia leads to altered neurochemical coding of the myenteric plexus and impairs the nitrergic response to nerve stimulation

Serum from achalasia patients alters neurochemical coding in the myenteric plexus and nitric oxide mediated motor response in normal human fundus

BACKGROUND AND AIMS

Achalasia is a disease of unknown aetiology. An immune mechanism has been suggested on the basis of previous morphological observations. The objective of this study was to test whether the serum of achalasia patients could reproduce the phenotype and functional changes that occur with disease progression in an ex vivo human model.

METHODS

Specimens of normal human fundus were maintained in culture in the presence of serum from patients with achalasia, gastro-oesophageal reflux disease (GORD), or healthy subjects (controls). Immunohistochemical detection of choline acetyltransferase (ChAT), neurone specific enolase (NSE), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), and substance P was carried out in whole mounts of gastric fundus myenteric plexus. In addition, the effects of achalasia serum on electrical field stimulation (EFS) induced contractions were measured in circular muscle preparations.

RESULTS

Serum from achalasia patients did not affect the number of myenteric neurones. Tissues incubated with serum from achalasia patients showed a decrease in the proportion of NOS (-26% of NSE positive neurones; p=0.016) and VIP (-54%; p=0.09) neurones, and a concomitant increase in ChAT neurones (+16%; p<0.001) compared with controls. In contrast, GORD serum did not modify the phenotype of myenteric neurones. Area under the curve of EFS induced relaxations (abolished by N-nitro-L-arginine methyl ester) was significantly decreased following incubation with serum from achalasia patients compared with controls (-7.6 (2.6) v -14.5 (5.0); p=0.036).

CONCLUSIONS

Serum from achalasia patients can induce phenotypic and functional changes which reproduce the characteristics of the disease. Further identification of putative seric factors and mechanisms involved could lead to the development of novel diagnostic and/or therapeutic strategies in achalasia.

Smith-Lemli-Opitz syndrome with a classical phenotype, oesophageal achalasia and borderline plasma sterol concentrations

The diagnostic biochemical hallmarks of Smith-Lemli-Opitz syndrome (SLOS) are elevated concentrations of the cholesterol precursors 7- and 8-dehydrocholesterol (7- and 8-DHC). We describe a patient with classical SLOS phenotype and oesophageal achalasia, which has not been reported in SLOS patients before. Plasma 7-DHC and 8-DHC were only marginally elevated. The diagnosis was confirmed by sterol analysis in cultured skin fibroblasts and mutation analysis.

[Regulation of the functional status of the lower esophageal sphincter with gastrointestinal hormones in cardiospasm and reflux esophagitis]

A role of gastrointestinal hormones in the regulation of the lower esophageal sphincter was studied in 22 patients with cardiospasm and 21 with reflux esophagitis. The levels of gastrin, vasoactive intestinal polypeptide (VIP), glucagon, insulin, and c peptide were determined by radioactive assay before and after surgical treatment. In opposite abnormalities (cardiospasm and reflux esophagitis), there is a different degree of VIP secretion both at the beginning and after functional exercises. Before and after functional exercises, the level of VIP was higher than in those with cardiospasm. The value of VIP on fasting and after functional exercises may be an additional information to establish the diagnoses of cardiospasm and reflux esophagitis and to evaluate the efficiency of the treatment performed.

Familial adrenocorticotropin unresponsiveness associated with alacrima and achalasia: biochemical and molecular studies in two siblings with clinical heterogeneity

The syndrome of familial adrenocorticotropin (ACTH) unresponsiveness is a rare form of primary adrenal insufficiency, usually without mineralocorticoid deficiency. It is characterized by elevated plasma ACTH concentrations and undetectable plasma cortisol levels not responding to exogenous ACTH. Alacrima and achalasia have also been occasionally associated with adrenal insufficiency (triple A syndrome). Pathogenetic mutations have been identified in the ACTH receptor gene in families with isolated familial ACTH unresponsiveness. Whether the ACTH receptor represents the locus of the defect for the triple A syndrome is not known. Here we report two siblings with familial ACTH unresponsiveness who were discrepant for skin pigmentation and mineralocorticoid function. In addition, achalasia and alacrima were documented only in the older sibling. The boy, studied at the age of 2 years, was hyperpigmented, in contrast to his normally pigmented sister, studied at the age of 9 years; basal plasma alpha-melanocyte stimulating hormone immunureactivity levels were 79 and 38 pg/ml, respectively (normal < 40 pg/ml). Furosemide-induced diuresis resulted in normal rises of plasma renin activity in both patients; however, plasma aldosterone levels increased only in the boy and not in his sister. Screening for abnormalities of the ACTH receptor gene by single strand conformation polymorphism analysis revealed no abnormality. Direct sequencing of the entire coding area of the ACTH receptor gene was also normal.

CONCLUSION

The syndrome of familial ACTH unresponsiveness can vary clinically and biologically within the same family.(ABSTRACT TRUNCATED AT 250 WORDS)

Megaesophagus in nine ferrets

Megaesophagus was diagnosed in 9 adult ferrets. Clinical history of the ferrets included regurgitation, difficulty in swallowing, partial anorexia, and lethargy. Cachexia, dehydration, weakness, and ptyalism were observed on physical examination. Radiography revealed the esophagus of each ferret to be dilated in the thoracic and cervical regions. Of 4 ferrets that had lymphocytopenia, 2 had concurrent leukopenia. Serum biochemical analysis revealed high activity of alanine transaminase (4 ferrets) and aspartate transaminase (3), and hypoglycemia (4). Treatment included administration of fluid, antibiotics, and agents directed against possible primary causes of megaesophagus. Treatments were ineffective, and all of the ferrets died or were euthanatized. All 6 ferrets that were submitted for necropsy had bronchopneumonia, hepatic lipidosis, mild esophagitis, and gastritis. The etiopathogenesis of megaesophagus in the ferrets was not determined.

Megaoesophagus in rats: a clinical, pathological and morphometrical study

Megaoesophagus was observed in 82 Long-Evans rats aged 3-32 months. Clinically, the hair was coarse, the neck distended, the mouth opened, wetted by saliva and soiled by bedding material, and the respiration characterized by tachypnoea and inspiratory crackles. By radiography, after barium administration, the oesophagus was seen to be dilated and filled with impacted dry food in the precardial region. The size of the dilatation varied depending on the oesophageal region and reached a diameter of 12 mm in the most severe case. Histologically, the muscular layers of the dilated portions showed focal inflammation and single fibre necrosis. Each affected oesophagus had (1) an increased circumference and radius and a reduced number of myenteric ganglion cells in both the thoracic and abdominal portions, and (2) a decreased thickness of the muscular layers in the thoracic portion and at the level of the cardia. A simple geometrical model showed that the reduced ganglion cell number was not due to a change in shape of the dilated oesophagus. Since no sign of infectious disease was found in these animals, and rats of other strains kept at the same time under the same conditions were not affected, a hereditary aetiology is suggested.

Transcutaneous electrical nerve stimulation decreases lower esophageal sphincter pressure in patients with achalasia

Vasoactive intestinal peptide (VIP) is believed to be an inhibitory neurotransmitter responsible for lower esophageal sphincter (LES) relaxation. In patients with achalasia the concentration of VIP and the number of VIP-containing nerve fibers are reduced or absent. It has been suggested that the response to low-frequency transcutaneous electrical nerve stimulation (TENS) may be mediated by a nonadrenergic noncholinergic pathway in which the release of VIP is responsible for the smooth muscle relaxation. The present study was designed to evaluate the effect of TENS on LES pressure and on VIP plasma concentrations in six patients with achalasia (five female, one male). TENS was performed daily during one week for 45-min sessions with a pocket stimulator that delivered low-frequency pulses (6.5 Hz), at 10 pulses/sec of 0.1-msec duration at intensities of 10-20 mA until rhythmic flexion of the fingers was obtained without producing pain. LES pressure and VIP levels were obtained before TENS, after the first 45-min session, and after a week of daily stimulation. After 45-min, TENS produced a significant reduction (P less than 0.01) in LES resting pressure from the mean value 56 +/- 6.4 mm Hg to 42.3 +/- 6.4 mm Hg; with LES relaxation improvement from 50.6 +/- 3% to 63.1 +/- 3.2% (P less than 0.01). After one week of daily TENS, an additional reduction in LES resting pressure (40.3 +/- 4 mm Hg) was observed (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal perforation during pneumatic dilatation for achalasia: a possible association with malnutrition

Pneumatic balloon dilatation of the lower esophageal sphincter is commonly utilized as primary therapy for achalasia. Perforation related to pneumatic dilatation is uncommon (2-6%) but may result in severe morbidity. Factors associated with risk of perforation are not well defined. We noted perforation in three patients undergoing forceful balloon dilatation. All these patients had clinical evidence of significant malnutrition (recent marked weight loss and severe hypoalbuminemia). Malnutrition may be a causal factor for perforation in patients with achalasia undergoing dilatation.

Serum uric acid levels in Chagas' disease

Uricemia was studied in a sample of 192 individuals from a highly endemic site for Chagas' disease (Bambuí, State of Minas Gerais, Brazil). The sample had 50 serologically negative individuals (controls) and the positive ones were classified on the basis of the presence of electrocardiographic alterations (63), altered esophageal emptying (16), or without any sign on symptom of the disease (76). Only the individuals with the digestive form of chronic Chagas' disease showed hyperuricemia, when compared with the appropriate controls. Family data suggest that hyperuricemia is an effect of the digestive pathology, rather than a cause, since the non-infected sibs of the megaesophagous patients did not show elevated levels of serum uric acid. Possible mechanisms responsible for these findings are postulated.

Successful treatment of esophageal dysmotility and Raynaud's phenomenon in systemic sclerosis and achalasia by transcutaneous nerve stimulation. Increase in plasma VIP concentration

Dysphagia has been successfully treated by low-frequency transcutaneous nerve stimulation (TNS) in two patients with achalasia and in six patients with systemic sclerosis. A 30- to 45-min stimulation session was followed by augmentation of peristalsis in the lower half of the esophagus and relaxation of the gastroesophageal sphincter, with relief of dysphagia. The sclerotic patients were also relieved of invaliding Raynaud's phenomenon. One 30-min daily stimulation session, and later one session every 2nd or 3rd day, was sufficient to prevent relapse. After months or years of TNS treatment the stimulation could in three patients be withdrawn with no recurrence. A stimulation session produced about 30% increase in plasma vasoactive intestinal polypeptides. Activation of this neuromodulator is considered to be the cause of the beneficial effects on dysphagia and Raynaud's phenomenon.

Effect of somatostatin on lower esophageal sphincter (les) pressure and serum gastrin in normal and achalasic subjects

Serum gastrin and lower esophageal sphincter (LES) responses to somatostatin infusion were evaluated in ten normal subjects and in nine achalasic patients in order to determine evidence of hormonal (presumably gastrin)control of LES pressure. After somatostatin infusion, a significant decrease of serum gastrin was observed in normal subjects at 30 min (81.6 +/- 3.2 versus 40.0 +/- 4.7 pg/ml; p less than 0.01) and a rapid increase of LES pressure was also observed (26.0 +/- 1.3 versus 34.1 +/- 1.6 mmHg; p less than 0.01). In achalasia no change was observed in serum gastrin concentration after somatostatin infusion. LES pressure at 20 min however significantly decreased (45.8 +/- 7.6 versus 31.6 +/- 2.3 mmHg; p less than 0.05). Endogenous gastrin is not a major control factor for LES pressure in either normal or achalasic subjects.

Studies on exogenous and endogenous interaction of gastrin and secretin in a case of achalasia

Studies were carried out in a case of achalasia. Administration of secretin caused relaxation of the spastic condition of LES, and high levels of serum gastrin and lower levels of plasma secretin are suggested to be related with the abnormally spastic condition of LES in the patient.