Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France

OBJECTIVES

Symptoms of achalasia are often misinterpreted, resulting in delayed diagnosis. The aims of our study were (1) to estimate the evolution of clinical and radiological features of a large population of achalasic patients between two successive periods; and (2) to determine the influence of symptoms on diagnostic delay.

METHODS

Between 1980 and 1998, all achalasia patients treated in our unit were assessed at the time of manometric diagnosis for clinical and radiological features. These data were compared between two successive periods (1980-1994 and 1994-1998). Then, a correlation between the diagnostic delay, clinical and radiological data and symptoms was investigated.

RESULTS

Three hundred and forty-five consecutive achalasia patients were assessed (mean age at diagnosis, 56 years; mean diagnostic delay, 5.7 years). The duration of the disease was correlated with the oesophageal diameter (P = 0.0001). Dysphagia, chest pain and heartburn were more frequent in young patients (respectively, P = 0.003, 0.0001 and 0.001). Women had 1.7 times the risk of men for suffering of chest pain (95% CI, 1.1 -2.6) and 2.2 times the risk for heartburn (95% CI, 1.2-4.0). Pulmonary involvement was more frequent when the oesophagus was dilated (P = 0.0002), and 3.4 times more frequent when associated with regurgitations (95% CI, 1.3-8.9). The oesophageal diameter was significantly smaller (38 vs 48 mm) in the last period, but we have not observed any significant shortening of the diagnostic delay. No symptoms influenced the diagnostic delay.

CONCLUSIONS

Despite a smaller oesophageal diameter at the time of diagnosis, during the period 1994-1998, diagnostic delay was not reduced. No clinical features associated with late diagnoses could be identified.

[Severe mixed thrombopenia during interferon treatment for chronic viral hepatitis C]

BACKGROUND

Thrombocytopenia occurred in a woman given alpha interferon for chronic hepatitis C without cirrhosis. Both central thrombocytopenia, clearly demonstrated, and peripheral thrombocytopenia, probably of autoimunne origin, were involved.

CASE REPORT

A 55-year-old woman with active chronic hepatitis C (Metavir score A2, F2) was given alpha interferon. One month after treatment onset, she developed thrombocytopenia (32 G/L). A second bone marrow aspirate and osteomedullary biopsy evidenced megalokaryocytes and the platelet count responded to polyvalent immunoglobulins. Five months after discontinuing interferon, the platelet count progressively returned to normal.

DISCUSSION

Central thrombocytopenia is classically described in patients given interferon and usually appears during the first weeks of treatment. In our case, the central mechanism was clearly demonstrated by the bone marrow aspirate and osteomedullary biopsy findings at a time when the platelet count was 32 G/L. A peripheral immunological participation was more difficult to prove but was strongly suggested by the persistence of thrombocytopenia despite the interruption of the interferon and the efficacy of immunoglobulins.

Risk factors for immediate complications after progressive pneumatic dilation for achalasia

OBJECTIVE

The aim of this retrospective study was to determine the risk factors of early complications after progressive pneumatic dilation for achalasia.

METHODS

Five hundred four dilations were performed in 237 consecutive achalasic patients between 1980 and 1994 with the same technique: low-pressure pneumatic dilation every other day with balloons of increasing diameter until success criteria were obtained (depending on manometric examination and esophageal x-ray transit performed 24 h after each dilation). Clinical, radiographical, endoscopical, and manometrical data as technical procedure characteristics for patients with perforations or other early complications were compared with those without complications.

RESULTS

We observed 15 complications (6% of patients): 7 perforations (3%), 3 asymptomatic esophageal mucosal tears, 4 esophageal hematomas, and 1 fever. Perforations occurred in 6 of 7 patients during the first dilation. The mean age was 68.5 yr in the group with complications versus 56.4 yr for the remainder (p < 0.05). Two deaths occurred in patients older than 90 yr. Instability of the balloon during dilations was noted in 8 of 15 cases of complications versus 57 of 222 patients (p < 0.05). No other data differed significantly.

CONCLUSIONS

This study showed a low prevalence of early complications using this progressive technique. Patients with hiatal hernia, esophageal diverticulum, or vigorous achalasia may safely undergo progressive pneumatic dilation. Only patients older than 90 yr should be referred for progressive pneumatic dilation with caution. Most of perforations arose during the first dilation, but there was no predictive pretherapeutic factor of perforation.

[Acute thrombosis of the portal system. Treatment with alteplase and heparin or with heparin alone in 10 patients]

OBJECTIVES

We report the efficacy of alteplase (a recombinant tissue plasminogen activator) with heparin or heparin alone in the treatment of acute thrombosis of the portal venous system.

METHODS

Ten consecutive patients with acute portal venous system thrombosis were studied. Five patients were treated with alteplase and heparin, and the remaining 5 patients, who were asymptomatic or had a contraindication to alteplase, were treated with heparin alone.

RESULTS

In 3 of the 5 patients treated with alteplase, ultrasonography showed total resolution of the thrombus; the remaining 2 had partial resolution of the thrombus. In 4 of the 5 patients treated with heparin alone, ultrasonography showed total resolution of the thrombus, and no change in one. No bleeding occurred.

CONCLUSION

Treatment with heparin can result in complete recanalisation of acute portal venous system thrombosis. These data suggest that combined therapy with systemic alteplase does not increase the efficacy of heparin.

[Acute reversible pan-dysautonomia: effect of erythromycin on gastrointestinal involvement]

We describe a case of acute autonomic neuropathy in an 18-year-old woman. Gut dysfunction was sufficiently severe for the patient to undergo laparotomy for suspected mechanical-intestinal obstruction before the diagnosis was made. Apart from the gut, other organs affected included the pupils, sweat and lachrymal glands. Cardiovascular autonomic function tests showed the involvement of sympathetic adrenergic nerves. Small bowel barium X-ray showed resolution of gastric stasis and emergence of jejunum dilatation during intravenous administration of erythromycin but this treatment did not eliminate intestinal obstructive symptoms. The patient had an incomplete recovery in 3 months. Erythromycin might have therapeutic value in patients with intestinal motility dysfunction in acute dysautonomia.