Gastric emptying of solid meals in achalasic patients after successful pneumatic dilatation of the cardia

Cardiovascular dysautonomia in Achalasia Patients: Blood pressure and heart rate variability alterations

Achalasia is a disease characterized by the inability to relax the esophageal sphincter due to a degeneration of the parasympathetic ganglion cells located in the wall of the thoracic esophagus. Achalasia has been associated with extraesophageal dysmotility, suggesting alterations of the autonomic nervous system (ANS) that extend beyond the esophagus. The purpose of the present contribution is to investigate whether achalasia may be interpreted as the esophageal manifestation of a more generalized disturbance of the ANS which includes alterations of heart rate and/or blood pressure. Therefore simultaneous non-invasive records of the heart inter-beat intervals (IBI) and beat-to-beat systolic blood pressure (SBP) of 14 patients (9 female, 5 male) with achalasia were compared with the records of 34 rigorously screened healthy control subjects (17 female, 17 male) in three different conditions: supine, standing up, and controlled breathing at 0.1 Hz, using a variety of measures in the time and spectral domains. Significant differences in heart rate variability (HRV) and blood pressure variability (BPV) were observed which seem to be due to cardiovagal damage to the heart, i.e., a failure of the ANS, as expected according to our hypothesis. This non-invasive methodology can be employed as an auxiliary clinical protocol to study etiology and evolution of achalasia, and other pathologies that damage ANS.

Clinical Effect of Endoscopic Pneumatic Dilation for Achalasia

Although pneumatic dilation is an accepted method for the treatment of achalasia, this therapy has high recurrence and complication rates, and prolonged follow-up studies on the parameters associated with various outcomes are rare. In this prospective 10-year follow-up study, a satisfactory therapeutic effect was achieved without serious complications. We report the therapeutic experience with pneumatic dilation, having aimed to evaluate the long-term clinical safety and efficacy of pneumatic dilation. In total, 35 consecutive patients with idiopathic achalasia who underwent pneumatic dilation were followed up at regular intervals in person or by a phone interview over a 10-year period. The mean duration of the follow-up was 43.03 ± 26.34 months (range 6-120 months). Remission was assessed by the dysphagia classification and symptom scores. Patients' clinical symptom scores were calculated before and at 6 to 36  months, 37 to 60  months, and >60  months after therapy. The influence of the patients' age, gender, and disease duration on the therapeutic effect was analyzed. The success rate of the operation was 97.2% (35/36), without massive hemorrhaging, perforation or other serious complications. Dysphagia after the therapy was significantly eased (P < 0.01). In total, 35 patients have been followed up for 6 to 36  months after therapy, 21 cases for 37 to 60  months, and 5 cases for >60  months, and the patients' symptom scores separately decreased significantly compared with the pretherapy scores (P < 0.01). For these patients, the 6 to 36  months remission rate was 85.7% (30/35), the 37 to 60  months rate was 61.9% (13/21), and the >60  months rate was 40% (2/5). The dilation effect had no relationship to the patient's age, gender, and disease duration (P > 0.05). The patients in 30 cases (85.7%) were successfully treated with a single dilation, in 4 cases (11.4%) with 2 dilations, and in 1 case (2.9%) with 3 dilations. These results suggest that endoscopic pneumatic dilation is an achalasia therapy with a good response; it is a simple and safe procedure with long-term clinical effectiveness. It is a preferred method in the treatment of achalasia.

Hypnosis and upper digestive function and disease

Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.

Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa

OBJECTIVES

Gastrointestinal symptoms are common in anorexia and in bulimia nervosa, but their relationship with gastric dysmotility and their possible improvement with refeeding are still debated.

METHODS

Twenty-three anorexic patients (12 with the binge/purging and 11 with the restricting subtypes) were studied using an ultrasonographic gastric-emptying test, psychopathological questionnaires, and bowel symptom questionnaires, before and after 4 and 22 wk rehabilitation.

RESULTS

Gastric symptom scores were markedly higher in patients than in controls and improved significantly with treatment. On entry, compared to controls, gastric emptying was significantly delayed in restricters and purgers (357 +/- 25.3 and 360 +/- 13.0 min, respectively, mean +/- SEM; controls 207 +/- 9.1). After 4 and 22 wk of treatment, it improved in restricters (315 +/- 20.1 and 296 +/- 17.2 min, respectively), but not in purgers (337 +/- 14.3 and 335 +/- 15.9 min). No relationship was found between entry values of symptoms of gastric emptying and of psychopathological tests or between their variations over time.

CONCLUSIONS

Gastric emptying derangement and dyspeptic symptoms are present in both subtypes of anorexia nervosa patients. Long-term rehabilitation improves gastrointestinal symptoms, gastric emptying, and psychopathological distress in an independent manner, whereas short-term refeeding does not.

Real-time ultrasonographic assessment of antroduodenal motility after ingestion of solid and liquid meals by patients with functional dyspepsia

BACKGROUND AND AIMS

Although antroduodenal motility has usually been studied by using manometric or scintigraphic methods, ultrasonography is an established, non-invasive method to evaluate duodenogastric motility. We used ultrasonography to evaluate gastric motility in patients with functional dyspepsia.

METHODS

Sixty-four patients with functional dyspepsia and 36 asymptomatic healthy subjects were given liquid and solid test meals. We investigated the gastric emptying rate, motility index, and duodenogastric reflux for the liquid meal and gastric emptying time, half-emptying time, and motility index for the solid meal.

RESULTS

After the liquid meal, the gastric emptying rate and motility index were significantly lower and the duodenogastric reflux was significantly higher in functional dyspepsia patients than in healthy subjects. After the solid meal, gastric emptying time, half-emptying time and the motility index were significantly lower in the patients than in the healthy subjects. Delayed gastric emptying of both meals occurred in only 20.3% of patients. Delayed emptying of the liquid or solid meal occurred in 62.5% of patients. In both groups, gastric emptying time of the solid meal was positively correlated with the motility index at 15 min post-ingestion.

CONCLUSION

In functional dyspepsia patients, delayed gastric emptying of a solid meal was related to antral hypomotility during the early postprandial phase. Ultrasonographic assessment of gastric motility in both liquid and solid meals may provide a better understanding of the pathogenesis of functional dyspepsia.

Simultaneous measurement of gastric emptying of a solid meal by ultrasound and by scintigraphy

OBJECTIVE

Although ultrasonic imaging may represent a valid alternative to scintigraphy for measurement of gastric emptying, most studies comparing the two methods have been carried out with liquid meals. The aim of this study was to compare scintigraphic and ultrasonographic measurements of gastric emptying of a solid meal in healthy subjects and in patients with possible delay in emptying.

METHODS

Nineteen subjects were studied: five controls, six patients with gastroesophageal reflux, and eight patients with dysmotility-like dyspepsia. Gastric emptying was measured by both scintigraphy and ultrasonography after ingestion of an 800-calorie solid, realistic meal containing 99mTc-labeled chicken liver. Scintigraphic measurements were made every 15 min for 6 h, and ultrasonic imaging of antral sections was undertaken every 15 min for the first 1 h and every 30 min thereafter. Total emptying times were calculated independently using the two methods, and the emptying patterns recorded by the two methods were compared.

RESULTS

Maximal antral dilation occurred 30 min (range 0-90 min) after the end of the meal and persisted until 96 +/- 42 min, by which time gastric radioactivity had decreased from its maximum by 43% +/- 23%. From this time on, the antral cross-sectional area returned toward the basal value, declining faster than the gastric counts recorded by scintigraphy. Total emptying times measured by ultrasound and by scintigraphy were in good agreement in all subjects, with a mean difference of only 4.5 min (limits of agreement, -17.1 to 21.6 min).

CONCLUSIONS

Ultrasonographic measurement of antral cross-sectional area provides a valid alternative to scintigraphy for the measurement of total gastric emptying of a solid meal. It is less reliable if other parameters of gastric emptying such as T(1/2) are required.

Esophageal and gastric nitric oxide synthesizing innervation in primary achalasia

OBJECTIVE

We performed a qualitative and quantitative analysis of the nitrinergic neurons in the esophageal and gastric component of the lower esophageal sphincter (LES) and gastric fundus of patients with primary achalasia.

METHODS

Four muscle strips were obtained from the esophagogastric junction (two from the esophageal and two from the gastric side of the LES), and two from the gastric fundus of six patients with endstage achalasia who underwent an esophagogastric myotomy plus hemifundoplication. Control specimens were obtained from eight patients who underwent surgery for cancer of the thoracic esophagus. Fixed sections were processed for NADPH-diaphorase histochemistry and the number (mean +/- SE) of nitrinergic neurons per section was visually quantified in each specimen.

RESULTS

In the controls, nitric oxide fibers were distributed to the muscle layer and surrounding myenteric neurons of both the LES and the gastric fundus. By contrast, achalasic patients showed a marked decrease of nitric oxide nerves and labeled neurons in both esophageal and gastric components of the LES and the gastric fundus. Quantitative assessment in achalasic patients showed that the mean number of nitrinergic neurons was dramatically reduced in both the esophageal (0.2 +/- 0.1) and the gastric component (2 +/- 0.6) of the LES as compared to those in controls (15 +/- 5 and 12 +/- 4, respectively; p < 0.05); nitrinergic neurons in the gastric fundus (3 +/- 1) were significantly reduced in comparison to those of controls (10 +/- 2) (p < 0.05).

CONCLUSIONS

Our results indicate that achalasia is a motor disorder with an intrinsic inhibitory denervation of the esophageal and gastric component of the LES and of the proximal stomach, thus providing further evidence for an extraesophageal extension of the disease.

Dysmotility of the small intestine in achalasia

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.

Autonomic dysfunction in patients with achalasia of the oesophagus

It has been suggested that achalasia is associated with extraoesophageal sympathetic and parasympathetic dysfunction. In a prospective study we applied conventional ultrasonography and duplex sonography to investigate basal and postprandial peak systolic velocity (PSV), pulsatility index (PI) and resistance index (RI) of superior mesenteric artery and PSV of portal vein in nine patients with achalasia and 10 healthy controls (study I). In addition, in eight of these patients autonomic nervous function was investigated by pupillary function tests as well as cardiovascular reflex tests and compared with eight age- and sex-matched controls (study II). The results indicated that postprandial increase of PSV in the superior mesenteric artery was significantly lower, and postprandial decrease of PI and RI significantly higher in achalasia compared to healthy controls. In contrast, postprandial increase of PSV in the portal vein was not significantly different between both groups. Autonomic function tests revealed significant lower maximal pupillary contraction and redilatation velocities, significantly lower heart rate variation during orthostasis, deep respiration test and Valsalva manoeuvre in achalasia compared to controls. It is concluded that achalasia is associated with extraoesophageal autonomic nervous dysfunction that involves cardiovascular and pupillary function as well as regulation of mesenteric arterial blood flow.

Symptomatic gastroparesis in a patient with achalasia

We present a case of a patient with achalasia who developed symptomatic gastroparesis after botulinum toxin injection therapy. Symptoms responded to prokinetics. Pathophysiology of gastric motility disturbances in patients with achalasia is discussed.

Gastric myoelectrical and antroduodenal motor activity in patients with achalasia

Achalasia is a primary motor disorder of the oesophagus, in which the myenteric plexus is involved. However, abnormalities in other parts of the digestive tract have also been described in achalasia. Whether gastric myoelectrical and duodenal motor activity in these patients is also affected is unknown. Therefore, interdigestive and postprandial gastric myoelectrical and antroduodenal motor activity were studied in 11 patients with achalasia, using electrogastrography (EGG) and stationary antroduodenal manometry. Electrogastrographically, no differences were found in the gastric frequency, incidence of dysrhythmias and postprandial/fasting power ratio. In the interdigestive state a lower propagation velocity of phase III episodes was found in the achalasia patients, but other parameters were unaltered. Postprandially, no differences were found in the number of pressure waves, in the amplitude of pressure waves or in antroduodenal coordination. We conclude that gastric myoelectrical activity and antral motor activity in patients with achalasia is normal, suggesting an intact extrinsic and intrinsic neural innervation of the distal stomach. Although postprandial duodenal motility is normal, a lower propagation velocity of phase III suggests involvement of the small intestine in achalasia.

Achalasia is not associated with measles or known herpes and human papilloma viruses

Achalasia is an esophageal motility disorder of unknown etiology. Several studies suggest possible herpes or measles virus etiology, but results are inconclusive. The aim of this study was to test whether herpesvirus (HV), measles (MV), or human papilloma virus (HPV) sequences could be detected in myotomy specimens from a wide spectrum of achalasia patients, using the polymerase chain reaction (PCR) technique. Myotomy specimens from 13 achalasia patients, esophagectomy specimens from nine esophageal cancer patients, and autopsy specimens from six fetuses were studied with the PCR technique. Paired oligonucleotide primers of HV (HSV-1 and 2, CMV, EBV, VZV, and HHV-6), MV and HPV sequences and exon 3 of the HPRT gene were used for the PCR DNA amplification. Amplified products were resolved on agarose gels and stained with ethidium bromide. All specimens yielded the appropriate-sized products for exon 3 of the HPRT and viral controls. No amplified products were seen in the achalasia specimens or controls corresponding to any of the virus sequences tested. The absence of HV, MV, and HPV sequences suggests that these viruses are not associated with achalasia but does not exclude the possibility of a previously unidentified virus as a causal agent. Further studies aimed at identifying an unknown viral agent as a cause for achalasia are warranted.

Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Autonomic dysfunction in patients with achalasia

It has been previously shown that patients with achalasia may have motor abnormalities of the stomach, small bowel and biliary system. This study investigates whether a disturbance of extraintestinal autonomic function occurs. Autonomic function studies were performed in 15 patients with achalasia and 15 age- and sex-matched healthy controls. Pupillograms were obtained during darkness, light exposure and after pilocarpine administration. Cardiovascular function studies included determinations of heart rate variation during deep breathing and orthostasis. In addition, we determined blood pressure changes in response to sustained handgrip, cold exposure and orthostasis. Neurohormonal function was investigated by measuring serum pancreatic polypeptide (PP) levels prior to and following sham feeding. Pupillary function did not differ in patients as compared with controls. However, 9 of 15 patients (95% CI: 32-84%) and none of the controls showed at least one abnormal autonomic cardiovascular response. A significant difference between the two groups was observed in sympathetic function (P = 0.023). More patients than controls did not respond to sham feeding with a PP increase. It is concluded that some patients with achalasia exhibit an abnormality of the autonomic nervous system that extends beyond the gastrointestinal tract. These abnormalities mainly concern cardiovascular function but may also involve neurohormonal responses.