Retrosternal pain subsequent to sclerotherapy

Pleuropulmonary complications of esophageal variceal sclerotherapy with absolute alcohol

BACKGROUND

Esophageal variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage. However, it causes a wide variety of local and systemic complications. The present study was performed to document pleuropulmonary complications of EVS with absolute alcohol.

METHODS

Twenty-six patients of portal hypertension of different etiologies were subjected to EVS with absolute alcohol. Baseline arterial blood gas analysis (PaO2, PaCO2, pH, HCO3, SaO2), chest X-ray and pulmonary function tests (forced expiratory volume at 1 s (FEV1), forced expiratory vital capacity (FVC), FEV1/FVC, maximum mid-expiratory flow rate (MMFR), and peak expiratory flow rate (PEFR)) were performed 4-6 h before the first session of EVS. These investigations were repeated within 24 h of EVS. Patients were asked to maintain a symptom diary and to record symptoms such as fever, chest pain, dysphagia and dyspnea during the study period.

RESULTS

Ten patients (38.46%) had chest pain and four patients (15.68%) had fever after sclerotherapy. Eight patients (30.54%) complained of dyspnea and six patients (23.08%) developed pleural effusion. There was a significant decline in FVC and FEV1 after EVS as compared with baseline values. However, FEV1/FVC ratio, MMFR and PEFR did not have any significant change.

CONCLUSIONS

Chest pain (38.46%), dyspnea (30.54%) and fever (15.68%) were the common symptoms after EVS while chest X-ray showed pleural effusion in 23.08%. Pulmonary function tests revealed a significant decline in FEV1 and FVC without change in FEV1/FVC ratio after EVS, suggesting a restrictive type of defect.

Ambulatory esophageal pH testing. Referral patterns, indication, and treatment in a Canadian teaching hospital

Over a 30-month period, 867 esophageal pH studies were conducted in a Canadian teaching hospital; of these, 315 tests were recorded in patients who were first-time referrals having no chest or upper gastrointestinal surgery and taking no medication that would affect the results. Patients were referred by gastroenterologists, general surgeons, ENT surgeons, thoracic surgeons, and a miscellaneous group. Patients were classified based on: pH results [abnormal = % total time pH < 4.0 (ie, > 6.0%)], manometry (abnormal = LES resting pressure < 5 mm Hg and/or abnormal peristalsis), and gender. Fifty-one percent (162/315) of the patient records demonstrated abnormal reflux. Intergroup comparisons of severity of reflux using two-way analysis of variance demonstrated no significant differences (P = 0.13). In the 162 patients who refluxed, 70% (N = 108) had normal motility studies; however, when the severity of reflux was compared, patients with abnormal motility (N = 54) demonstrated significantly more severe reflux (19.8 +/- 12.8 vs 16.2 +/- 11.3) P = 0.02. In those patients with abnormal manometry, no significant differences (P = 0.44) in the severity of reflux were found among those with abnormal peristalsis (N = 27), low resting pressure (N = 17), or a combination of aperistalsis and low LES pressure (N = 10). Symptomatic patients with reflux (N = 107) demonstrated a significantly greater percent time pH < 4.0 than those with asymptomatic reflux (N = 55); 18.1 +/- 11.5% vs 16.2 +/- 12.7%, P = 0.04. When the severity of reflux by gender was compared, no significant differences were found [18.3 +/- 11.9 (male) N = 91 vs 16.2 +/- 11.9 (female) N = 71, P = 0.11]. The results from this study show that: (1) esophageal pH testing is important in subspecialties other than gastroenterology and that the clinical yield is high in all referring groups, (2) esophageal pH testing and manometry are complimentary tests, but that reflux occurs commonly in association with normal manometry, (3) asymptomatic reflux was found in 34% of the patients with abnormal reflux scores, and (4) the severity of reflux in male and female patients is similar.

The extent and pattern of gastro-oesophageal reflux in patients with scleroderma oesophagus: the effect of low-dose omeprazole

Ambulatory 24-hour oesophageal pH studies were obtained from 11 patients with scleroderma who expressed either dysphagia (n = 6) or heartburn (n = 5) as their predominant oesophageal symptom. No significant differences were found in the extent of pattern of reflux between these two groups. The pH data of both scleroderma groups were combined and compared to an age- and sex-matched group of control subjects (n = 11). The reflux demonstrated by scleroderma patients was significantly greater than the control group in every category (P < 0.01). The percentage of time the pH was < 4.0 was not significantly different (P > 0.05) upright (29.9 +/- 19.8%) vs. supine (44.2 +/- 28.5%) in patients with scleroderma. Eight scleroderma patients underwent repeat pH studies while taking low-dose omeprazole (20 mg daily) and reflux was reduced significantly (P < 0.01) in all patients. The authors believe that 24-hour ambulatory oesophageal pH-monitoring should be routinely conducted in scleroderma patients to provide quantitative reflux data, even when heartburn is not expressed as a symptom. Omeprazole, 20 mg daily, provides adequate protection from the H+ component of the refluxate.

Prophylactic versus emergency sclerotherapy of large esophageal varices prior to liver transplantation

From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use of prophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P < 0.001), esophageal perforation 6.4-fold (P < 0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P < 0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P < 0.001). These data demonstrate that emergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy prevents variceal bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.

Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome

Anecdotal reports suggest that obstructive sleep apnea syndrome (OSAS) patients may suffer from frequent nocturnal gastroesophageal reflux (GER) and that nasal continuous positive airway pressure may be an effective form of antireflux therapy in this population. To confirm these clinical impressions, we performed two consecutive days of 24-h esophageal pH monitoring, nocturnal esophageal pressure recording, and polysomnography on six OSAS patients complaining of regular nocturnal GER. On night one, the patients were untreated. Five of six subjects had abnormal amounts of nocturnal GER. Arousal, movement and swallowing were more frequent (p less than 0.043) and nadir intrathoracic pressure lower (p less than 0.005) in the 30 s prior to precipitous drops in esophageal pH (greater than or equal to 2 pH units) than during random control periods. A direct association between obstructive apneas and GER was not identified. On night two, nasal CPAP was administered and successfully treated apnea in five of six subjects. In these patients, there was also dramatic reduction in GER frequency and duration on CPAP. The mean percentage of time pH less than 4 dropped from 6.3 +/- 2.1 to 0.1 +/- 0.1 percent (p less than 0.025). We believe that OSAS may predispose to nocturnal GER by lowering intrathoracic pressure and increasing arousal and movement frequency. Nasal CPAP can correct these predisposing factors and reduce GER.

Manometric evaluation of esophageal motility in patients submitted to prophylactic variceal sclerosis

Sclerotherapy of esophageal varices is an effective hemostatic treatment and may also prevent bleeding. In our study, we examined the effects of prophylactic sclerotherapy on esophageal motility in 15 patients with Child's A cirrhosis of the liver. All the patients underwent three manometric measurements, performed respectively before the sclerotherapy, 1 week after the eradication of varices, and 3 months later. The results of our study show that prophylactic sclerotherapy of esophageal varices does not significantly change the resting pressure and length of the lower esophageal sphincter. Neither the amplitude nor the duration of the postswallowing esophageal peristaltic waves is significantly influenced by sclerotherapy. However, sclerotherapy produces a significant increase in tertiary contractions in the distal esophagus, which could explain the onset of dysphagia among patients in whom postsclerotherapy stricture is not evident.

Esophageal motility disorders

Esophageal motility disorders consist of a complex array of disturbances in normal esophageal function associated with dysphagia, gastroesophageal reflux, and noncardiac chest pain. A thorough knowledge of normal esophageal anatomy and physiology is important to a full understanding of these motility derangements. Through a complicated interaction of neuromuscular and hormonal influences, the voluntary act of swallowing transforms into an automated sequence of peristaltic waves propelling food and liquids into the stomach in concert with coordinated relaxation of the sphincters. Anatomic and physiologic barriers exist within the esophagus protecting against gastroesophageal reflux and aspiration. With improvements in diagnostic tools such as barium contrast radiography, scintigraphy, pH measurements, and esophageal manometrics with provocative testing, motility disorders have become better defined and understood. Primary motility disorders consist of achalasia, diffuse esophageal spasm (DES), "nutcracker esophagus," hypertensive lower esophageal sphincter, and nonspecific esophageal motility dysfunction (NEMD). A host of secondary and miscellaneous motility disorders also affect the esophagus, including scleroderma and other connective tissue diseases, diabetes mellitus, Chagas' disease, chronic idiopathic intestinal pseudo-obstruction, and neuromuscular disorders of striated muscle. Gastroesophageal reflux disease (GERD) may also be promoted by associated motility disturbances. Treatment modalities include surgical myotomy; dilatation; and pharmacologic manipulations, including use of nitrates, calcium-channel blockers, H2-blockers, and psychotropic drugs where appropriate.

Reflux patterns in patients with achalasia without operation

Five patients with achalasia who had not had an operation underwent esophageal manometry and 24-hour, ambulatory pH monitoring to determine the pattern and extent of esophageal reflux. One patient had reflux within normal limits. In 2 patients, reflux occurred 0.5% of the total time and no episodes of supine reflux were recorded. In the 2 remaining patients, reflux was measured 16.8% and 55.3% of the total time; however, in both patients, these results were influenced by lengthy bouts of supine reflux. These indices of reflux were not influenced by differences in resting lower esophageal sphincter tone, position, or length. Twenty-four-hour esophageal pH monitoring can be useful in the preoperative assessment of patients with achalasia, and the information obtained might influence the choice of operative procedure.

Pericarditis: complication of esophageal sclerotherapy. A report of three cases

Three patients developed acute pericarditis while undergoing esophageal sclerotherapy for bleeding varices. One patient required pericardiocentesis and the other 2 patients had spontaneous resolution of the pericarditis. This previously unreported complication of sclerotherapy must be considered in the differential diagnosis of those patients who develop postsclerotherapy chest pain.

Reflux patterns following limited myotomy without fundoplication for achalasia

Five patients with achalasia underwent limited myotomy without fundoplication. Surgery reduced mean lower esophageal sphincter resting pressure significantly (p less than .05) from 31 +/- 9.7 mm Hg to 16.1 +/- 8.2 mm Hg. Twenty-four-hour ambulatory esophageal pH studies demonstrated that the percentage of time the pH in the distal esophagus was below 4 was similar whether the patient was upright or supine (6.6 +/- 6.5% of total time upright vs. 9.1 +/- 12.7% of total time). Reflux events that occur in the supine position may be significant because of their prolonged duration resulting from the absence of normal secondary peristalsis in the body of the esophagus. Patients with achalasia who have undergone esophagomyotomy without fundoplication do not appear to experience more reflux than control subjects with normal esophageal function.