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Chong Tai LI, Akil O, Nguyen KQ, Sharma A. End-Stage Achalasia With Megaesophagus Refractory to Two Heller Myotomies. Cureus 2024; 16:e55721. [PMID: 38586803 PMCID: PMC10998642 DOI: 10.7759/cureus.55721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Achalasia is a motility disorder of the esophagus in which the lower esophageal sphincter fails to relax. Megaesophagus is a rare complication of achalasia characterized by severe dilatation of the esophagus, often indicative of end-stage achalasia. Typical presenting symptoms include dysphagia, nausea, vomiting, weight loss, and chest pain. The majority of patients with achalasia typically have excellent outcomes after surgical intervention with Heller myotomy. We discuss an interesting case of unsuccessful surgical intervention and hypothesize the reason for its failure in our patient.
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Affiliation(s)
| | - Omar Akil
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Kimberly Q Nguyen
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Aryama Sharma
- Gastroenterology, Broward Health North, Deerfield Beach, USA
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2
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Abu Suleiman A, James D, Wilkins A, Bladel AV, Lo T. Achalasia-associated megaoesophagus presenting with dyspnoea and cough. BMJ Case Rep 2024; 17:e258950. [PMID: 38367990 PMCID: PMC10875499 DOI: 10.1136/bcr-2023-258950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2024] Open
Abstract
We present an unusual case of achalasia presenting with dyspnoea and persistent cough. These symptoms persisted for months, leading to the patient undergoing a chest X-ray by her general practitioner which showed right basal consolidation and a density extending along the right mediastinum. CT scan was done which revealed megaoesophagus with a diameter of 7 cm causing tracheal compression, as well as right basal consolidation, consistent with aspiration. Further history revealed 6-month history of progressive swallowing difficulty, retrosternal chest pain and shortness of breath which worsened when eating solid foods. After thorough workup, a diagnosis of idiopathic achalasia (type II) was made. She was treated with laparoscopic Heller cardiomyotomy and Dor fundoplication with significant improvement at follow-up. Dyspnoea and respiratory symptoms are unusual presenting symptoms, suggesting a need to consider achalasia in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis and intervention prior to oesophageal failure.
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Affiliation(s)
- Amro Abu Suleiman
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Daniel James
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Alexander Wilkins
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Adrian Van Bladel
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Terence Lo
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
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3
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Wasim AU, Khan MW, Khan OA, Almatraf KS. Acute-Onset Achalasia Following a Recent COVID-19 Infection: A Case Report. Cureus 2023; 15:e38803. [PMID: 37303428 PMCID: PMC10250781 DOI: 10.7759/cureus.38803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Achalasia is a rare esophageal motility disorder that leads to dysphagia, regurgitation, and several other symptoms. While the etiology of achalasia is not completely understood, studies have suggested an immune reaction to viral infections, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), as a potential cause. Here, we present a case report of a previously healthy 38-year-old male who presented to the emergency room with severe shortness of breath, recurrent vomiting, and dry cough, that had progressively worsened over five days. The patient was diagnosed with coronavirus disease 2019 (COVID-19), and a chest CT also revealed prominent features of achalasia with a markedly dilated esophagus and areas of narrowing at the distal esophagus. The initial management of the patient included IV fluids, antibiotics, anticholinergics, and corticosteroid inhalers which improved his symptoms. This case report highlights the importance of considering the acute-onset of achalasia in COVID-19 patients and the need for further research on the potential association between SARS-CoV-2 and achalasia.
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Affiliation(s)
- Asad Ullah Wasim
- Internal Medicine, Air University - Fazaia Medical College, Islamabad, PAK
- Division of Clinical and Translational Research, Larkin Community Hospital, Miami, USA
| | | | - Osama A Khan
- Internal Medicine, Al Iman General Hospital, Riyadh, SAU
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4
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Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options. Neurogastroenterol Motil 2023; 35:e14459. [PMID: 36153803 DOI: 10.1111/nmo.14459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/13/2022] [Accepted: 08/01/2022] [Indexed: 12/31/2022]
Abstract
Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.
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Affiliation(s)
- Sebastien Rolland
- Division of Gastroenterology, Hôpital Maisonneuve-Rosemont and Université de Montreal, Montreal, Quebec, Canada
| | - William Paterson
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
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5
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Pomenti S, Blackett JW, Jodorkovsky D. Achalasia: Diagnosis, Management and Surveillance. Gastroenterol Clin North Am 2021; 50:721-736. [PMID: 34717867 DOI: 10.1016/j.gtc.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.
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Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - John William Blackett
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA.
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6
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Goto O, Higuchi K, Tatsuguchi A, Koizumi E, Noda H, Onda T, Omori J, Kaise M, Iwakiri K. Novel Method of Sampling the Gastrointestinal Muscle Layer: Feasibility of Endoscopic Muscular Resection with a Ligation Device in an in Vivo Porcine Model. J NIPPON MED SCH 2021; 88:441-447. [PMID: 34789604 DOI: 10.1272/jnms.jnms.2021_88-602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastrointestinal muscular sampling is useful in the histological assessment of functional gastrointestinal disorders. We devised a new sampling method to obtain a large volume of muscle tissues and then investigated the feasibility and safety of endoscopic muscular resection with a ligation device in an in vivo porcine model. METHODS After establishing a submucosal tunnel, a rubber band was placed on the muscle tissue by sucking the exposed muscle layer. Thereafter, the established pseudopolyp was removed using an electrocautery snare, and the entry site of the submucosal tunnel was closed endoscopically. This procedure was performed at three sites in the esophagus and stomach of two pigs. The technical success, histology, and survival rate on postoperative day 7 were examined postoperatively. RESULTS We successfully completed the mentioned procedure in 11 of the 12 sites (92%), without the occurrence of severe adverse events. The median diameters of obtained tissues from the esophagus and stomach, respectively, were 5 mm and 10 mm. Histologically, both the inner and outer muscle layers were included in all specimens. The postprocedural course was found uneventful in both pigs during the observatory period. CONCLUSIONS Endoscopic muscular resection using a ligation device enabled us to obtain large and thick muscle tissue samples. This approach may facilitate more precise histological assessments of functional gastrointestinal disorders.
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Affiliation(s)
- Osamu Goto
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Kazutoshi Higuchi
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Atsushi Tatsuguchi
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Eriko Koizumi
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Hiroto Noda
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Takeshi Onda
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Jun Omori
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Mitsuru Kaise
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
| | - Katsuhiko Iwakiri
- Department of Gastroenterology and Hepatology, Nippon Medical School Hospital
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7
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Zhou MJ, Kamal A, Freedberg DE, Markowitz D, Clarke JO, Jodorkovsky D. Type II Achalasia Is Increasing in Prevalence. Dig Dis Sci 2021; 66:3490-3494. [PMID: 33089487 DOI: 10.1007/s10620-020-06668-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/08/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Three manometric subtypes of achalasia were defined in the Chicago Classification approximately 10 years ago: type I (aperistalsis), type II (pan-pressurization), and type III (spastic). Since the widespread use of this classification scheme, the evolving prevalence of these subtypes has not been elucidated. We aim to determine the prevalence of each subtype a decade after the adoption of the Chicago Classification. METHODS This is a retrospective cohort analysis of patients diagnosed with achalasia on high-resolution manometry (HRM) at two major academic medical centers between 2015 and 2018. Patients were excluded if they had a diagnosis of another esophageal motility disorder, previously treated achalasia, or foregut surgery. Demographic data, manometric subtype, and esophageal dilatation grade on endoscopy were obtained. Prevalence of achalasia subtypes was compared with a published historical control population (2004-2007). Fischer's exact and t tests were used for analysis. RESULTS Of 147 patients in the contemporary cohort and 99 in the historical control cohort, the prevalence of type I achalasia was 8% versus 21%, type II 63% versus 50%, and type III 29% versus 29%, respectively (p = 0.01). The mean age in our population was 58 years compared to 57 years in the historical control, and the proportion of men 48% versus 47%, respectively (p = 0.78). Mean endoscopic dilatation grade in the contemporary cohort was 1.5 for type I patients, 0.9 for type II, and 0.4 for type III, compared with 1.5, 0.6, and 0.4, respectively. Overall mean dilatation grade was 0.8 in our cohort versus 0.7 in the historical control (p = 0.58). CONCLUSION The prevalence of type II achalasia was significantly greater and prevalence of type I significantly less in our patient population compared to our predefined historical control. Other characteristics such as age and sex did not appear to contribute to these differences. Histopathological evidence has suggested that type II achalasia may be an earlier form of type I; thus, the increased prevalence of type II achalasia may be related to earlier detection of the disease. The adoption of HRM, widespread use of the Chicago Classification, and increased disease awareness in the past decade may be contributing to these changes in epidemiology.
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Affiliation(s)
- Margaret J Zhou
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - David Markowitz
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA.
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8
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Mari A, Abu Baker F, Pellicano R, Khoury T. Diagnosis and Management of Achalasia: Updates of the Last Two Years. J Clin Med 2021; 10:jcm10163607. [PMID: 34441901 PMCID: PMC8397142 DOI: 10.3390/jcm10163607] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.
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Affiliation(s)
- Amir Mari
- Department of Gastroenterology, Nazareth Hospital, Faculty of Medicine, Bar-Ilan University, Safed 16100, Israel
- Correspondence: ; Tel.: +972-46028814
| | - Fadi Abu Baker
- Hillel Yaffe Medical Center, Department of Gastroenterology and Hepatology, Hadera 38100, Israel;
| | | | - Tawfik Khoury
- Galilee Medical Center, Department of Gastroenterology, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
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9
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Wu XY, Liu ZQ, Wang Y, Chen WF, Gao PT, Li QL, Zhou PH. The etiology of achalasia: An immune-dominant disease. J Dig Dis 2021; 22:126-135. [PMID: 33583137 DOI: 10.1111/1751-2980.12973] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 02/06/2023]
Abstract
There is accumulating evidence suggesting that an autoimmune component is involved in esophageal achalasia. An increase in immune cells, cytokines, chemokines, and autoimmune antibodies in serum and infiltration of immune cells in tissues support the view that immune-mediated inflammation is a crucial pathogenesis of inhibitory neuron degeneration in the lower esophageal sphincter. Infection of viruses such as the herpes virus family has been suspected of provoking the autoimmune reaction. Meanwhile, previous reports on immunogenetics have proposed that specific risk alleles on the human leukocyte antigen complex define the susceptible population to achalasia. In this study we reviewed current knowledge regarding the immune-related factors of achalasia, including immunology, viral infection and immunogenetic variations.
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Affiliation(s)
- Xing Yue Wu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Zu Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping Ting Gao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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10
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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11
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Rieder E, Fernandez-Becker NQ, Sarosiek J, Guillaume A, Azagury DE, Clarke JO. Achalasia: physiology and diagnosis. Ann N Y Acad Sci 2020; 1482:85-94. [PMID: 33140485 DOI: 10.1111/nyas.14510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.
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Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jerzy Sarosiek
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
| | - Alexandra Guillaume
- Gastrointestinal Motility Center, Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Dan E Azagury
- Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
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12
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Doubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg 2020; 111:1717-1723. [PMID: 32891651 DOI: 10.1016/j.athoracsur.2020.06.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.
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Affiliation(s)
- Maria Doubova
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hassan Robaidi
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Farid M Shamji
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - R Sudhir Sundaresan
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick James Villeneuve
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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13
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Lottrup C, Khan A, Rangan V, Clarke JO. Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view. Ann N Y Acad Sci 2020; 1481:182-197. [PMID: 32648992 DOI: 10.1111/nyas.14417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.
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Affiliation(s)
- Christian Lottrup
- Department of Medicine, Aalborg University Hospital, Hobro, Denmark.,Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Abraham Khan
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John O Clarke
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California
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14
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Sato H, Yokomichi H, Takahashi K, Tominaga K, Mizusawa T, Kimura N, Kawata Y, Terai S. Epidemiological analysis of achalasia in Japan using a large-scale claims database. J Gastroenterol 2019; 54:621-627. [PMID: 30607612 DOI: 10.1007/s00535-018-01544-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/26/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Achalasia is a well-known esophageal motility disorder, but epidemiological studies in Japan are lacking. We investigated the incidence and period prevalence of achalasia in Japan, including the rate of coexistence of esophageal carcinoma, and evaluated treatment trends. METHODS To estimate the nationwide number of patients with achalasia, a large-scale insurance claims database from 2005 to 2017 were used for our analyses. Patients with achalasia and coexistence of esophageal carcinoma were identified based on the diagnosis code registered. Interventional treatment was also evaluated. RESULTS Of the total 5,493,650 populations, 385 were diagnosed with primary achalasia. The incidence was calculated as 0.81-1.37 per 100,000 person-years (male-to-female ratio was almost 1; mean age at diagnosis was 43.3 ± 14.4 years). The period prevalence was 7.0 per 100,000 persons. There were statistically significant trends of increase in the incidence and period prevalence over age groups (all p values < 0.0001). Four men with achalasia developed esophageal carcinoma, and the incidence of esophageal carcinoma with achalasia was estimated as 0.25 per 100 person-years. With regard to intervention, esophageal dilation was performed as a first treatment in 64.7% of patients, with repeat intervention required in 56.9% of these. The proportion of patients treated using peroral endoscopic myotomy (POEM) increased annually to 41.1% in 2017. CONCLUSIONS In Japan, the incidence and period prevalence of achalasia is comparable to that in other countries. The absolute risk of esophageal carcinoma is rather low. Esophageal dilation has been the mainstay of achalasia treatment, and the role of POEM has increased annually.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan.
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Chuo City, Yamanashi, Japan
| | - Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Takeshi Mizusawa
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Naruhiro Kimura
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Yuzo Kawata
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
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15
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Furuzawa-Carballeda J, Boon L, Torres-Villalobos G, Romero-Hernández F, Ugarte-Berzal E, Martens E, Vandooren J, Rybakin V, Coss-Adame E, Valdovinos M, Velazquez-Fernández D, Opdenakker G. Gelatinase B/Matrix Metalloproteinase-9 as Innate Immune Effector Molecule in Achalasia. Clin Transl Gastroenterol 2018; 9:208. [PMID: 30449890 PMCID: PMC6240577 DOI: 10.1038/s41424-018-0076-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/28/2018] [Accepted: 10/22/2018] [Indexed: 02/06/2023] Open
Abstract
Objectives Achalasia is a primary esophageal motility disorder resulting from selective loss of inhibitory neurons in the esophageal myenteric plexus, likely due to an autoimmune response with involvement of the adaptive immune system. Innate immune processes of the host constitute the bridge between environmental etiological factors and the adaptive immune system. Although these remain poorly investigated, they might be of diagnostic and therapeutic relevance. In view of the role of extracellular proteolysis in organ-specific autoimmunity, we studied gelatinases of the matrix metalloproteinase (MMP) family in achalasia patients. Methods The presence of MMP-2 and MMP-9 proteoforms was analyzed in sera of two cohorts of achalasia patients. Additionally, with the use of immunohistopathological analysis, in situ MMP-2 and MMP-9 expression was investigated. Finally, we tested the paradigm of remnant epitopes generating autoimmunity (REGA) for achalasia-associated autoantigens by evaluating whether autoantigenic proteins are cleaved by MMP-9 into remnant epitopes. Results We showed significantly increased ratios of MMP-9/MMP-2 and activated MMP-9/proMMP-9 in sera of achalasia patients (n = 88) versus controls (n = 60). MMP-9-positive and MMP-2-positive cells were more abundant in achalasia (n = 49) versus control biopsies from transplant donors (n = 10). Furthermore, extensive damage within the plexus was found in the tissues with more MMP-9-positive cells. Additionally, we documented achalasia-associated autoantigens PNMA2, Ri, GAD65, and VIP as novel MMP-9 substrates. Conclusions We provide new biomarkers and insights into innate immune mechanisms in the autoimmune pathology of achalasia. Our results imply that extracellular protease inhibition is worthwhile to test as therapeutic intervention in achalasia.
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Affiliation(s)
- Janette Furuzawa-Carballeda
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Lise Boon
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium
| | - Gonzalo Torres-Villalobos
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernanda Romero-Hernández
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Estefania Ugarte-Berzal
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium
| | - Erik Martens
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium
| | - Jennifer Vandooren
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium
| | - Vasily Rybakin
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium
| | - Enrique Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel Valdovinos
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Velazquez-Fernández
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ghislain Opdenakker
- Department of Microbiology and Immunology, Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven, University of Leuven, Leuven, Belgium.
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16
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Vackova Z, Niebisch S, Triantafyllou T, Becker J, Hess T, Kreuser N, Kanoni S, Deloukas P, Schüller V, Heinrichs SK, Thieme R, Nöthen MM, Knapp M, Spicak J, Gockel I, Schumacher J, Theodorou D, Martinek J. First genotype-phenotype study reveals HLA-DQβ1 insertion heterogeneity in high-resolution manometry achalasia subtypes. United European Gastroenterol J 2018; 7:45-51. [PMID: 30788115 DOI: 10.1177/2050640618804717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022] Open
Abstract
Background Achalasia is a primary oesophageal motility disorder. Although aetiology remains mainly unknown, a genetic risk variant, rs28688207 in HLA-DQB1, showed strong achalasia association suggesting involvement of immune-mediated processes in the pathogenesis. High-resolution manometry recognises three types of achalasia. The aim of our study was to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 across the high-resolution manometry subtypes. Methods This was a cross-sectional retrospective study. Achalasia patients from tertiary centres in the Czech Republic (n = 163), Germany (n = 114), Greece (n = 70) and controls were enrolled. All subjects were genotyped for the rs28688207 insertion. The Kruskal-Wallis test was used for the genotype-phenotype analysis. Results A total of 347 achalasia patients (type I - 89, II - 210, III - 48) were included. The overall frequency of the rs28688207 was 10.3%. The distribution of the insertion was significantly different across the high-resolution manometry subtypes (p = 0.038), being most prevalent in type I (14.6%), followed by type II (9.5%) and III (6.3%). Conclusion The frequency of the HLA-DQB1 insertion differs among high-resolution manometry achalasia subtypes. The insertion is most prevalent in type I, suggesting that immune-mediated mechanisms triggered by the insertion may play a more prominent role in the pathogenesis of this subtype.
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Affiliation(s)
- Zuzana Vackova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Stefan Niebisch
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tania Triantafyllou
- Foregut Surgery Department, Hippokration General Hospital of Athens, Athens, Greece
| | - Jessica Becker
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - Timo Hess
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - Nicole Kreuser
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Stavroula Kanoni
- William Harvey Research Institute, University of London, London, UK
| | - Panos Deloukas
- William Harvey Research Institute, University of London, London, UK
| | - Vitalia Schüller
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - Sophie Km Heinrichs
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Markus M Nöthen
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - Michael Knapp
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University of Bonn, Bonn, Germany
| | - Julius Spicak
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Johannes Schumacher
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Genomics, University of Bonn, Bonn, Germany
| | - Dimitris Theodorou
- Foregut Surgery Department, Hippokration General Hospital of Athens, Athens, Greece
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Institute of Physiology, Charles University in Prague, Prague, Czech Republic.,Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
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17
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Kim H, Park H, Choi H, Shin Y, Park H, Youn YH, Kim JH. Retention Esophagitis as a Significant Clinical Predictor of Progression to Esophageal Cancer in Achalasia. Clin Endosc 2018; 51:161-166. [PMID: 29506341 PMCID: PMC5903079 DOI: 10.5946/ce.2017.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/01/2017] [Accepted: 11/01/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Chronic liquid and/or food stasis caused by retention esophagitis (RE) in achalasia is a notable endoscopic finding because of the presence of a thickened or whitish esophageal mucosa and histologically altered squamous hyperplasia. We aimed to identify the clinical features of RE associated with achalasia and to clarify the clinical definition of RE in achalasia as a precancerous lesion identified by analyzing biomarker expressions. Methods From 2006 to 2015, we retrospectively reviewed 37 patients with achalasia without previous treatment. Among them, 21 patients had diagnostic findings of RE (RE+) and 16 patients had no diagnostic findings of RE (RE–). Immunohistochemical staining of p53, p16, and Ki-67 was performed on the endoscopic biopsy tissues from the patients with achalasia and 10 control patients with non-obstructive dysphagia. Results The symptom duration and transit delay were significantly longer in the RE+ group than in the RE– group. We found particularly high p53 positivity rates in the RE+ group (p<0.001). The rate of p16 expression was also significantly higher in the RE+ group than in the other two groups (p=0.003). Conclusions A high p53 expression rate was more frequently found in the RE+ group than in the other two groups. RE could be a meaningful clinical feature of achalasia for predicting esophageal carcinogenesis.
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Affiliation(s)
- Haewon Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Digestive Disease Center and Research Institute, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - HeeSeung Choi
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yooju Shin
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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18
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Câmara ERZ, Madureira FAV, Madureira D, Salomão RM, Iglesias ACRG. LATE EVALUATION OF DYSPHAGIA AFTER HELLER ESOPHAGEAL MYOTOMY WITH DOR FUNDOPLICATION FOR ACHALASIA. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2017; 30:182-186. [PMID: 29019558 PMCID: PMC5630210 DOI: 10.1590/0102-6720201700030005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/06/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND All available treatments for achalasia are palliative and aimed to eliminate the flow resistance caused by a hypertensive lower esophageal sphincter. AIM To analyze the positive and negative prognostic factors in the improvement of dysphagia and to evaluate quality of life in patients undergoing surgery to treat esophageal achalasia by comparing findings before, immediately after, and in long follow-up. METHODS A total of 84 patients who underwent surgery for achalasia between 2001 and 2014 were retrospectively studied. The evaluation protocol with dysphagia scores compared preoperative, immediate (up to three months) postoperative and late (over one year) postoperative scores to estimate quality of life. RESULTS The surgical procedure was Heller-Dor in 100% of cases, with 84 cases performed laparoscopically. The percent reduction in pre- and immediate postoperative lower esophageal sphincter pressurewas 60.35% in the success group and 32.49% in the failure group. Regarding the late postoperative period, the mean percent decrease was 60.15% in the success group and 31.4% in the failure group. The mean overall drop in dysphagia score between the pre- and immediate postoperative periods was 7.33 points, which represents a decrease of 81.17%. CONCLUSIONS Reduction greater than 60% percent in lower esophageal sphincter pressurebetween the pre- and postoperative periods suggests that this metric is a predictor of good prognosis for surgical response. Surgical treatment was able to have a good affect in quality of life and drastically changed dysphagia over time.
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Affiliation(s)
| | | | - Delta Madureira
- General Surgery Clinic, Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Renato Manganelli Salomão
- General Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro
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19
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Abstract
This review examines the etiology and pathogenesis of idiopathic achalasia. This disease is clinically characterized by dysphagia of solids and liquids due to the presence of simultaneous or absent esophageal contractions and impaired or absent relaxation of the lower esophageal sphincter. It includes a review of (a) etiology and pathogenesis of this inflammatory process that damage the ganglion cells of the Auerbach plexus that is limited to the esophagus; (b) genetic abnormalities and polymorphisms associated with this disease that may help explain its heterogeneity expressed by the different motility abnormalities of its phenotypes as well as differences in its clinical progression. These different genetic abnormalities may be responsible for the slow progression of types I or II phenotypes; (c) indirect evidence of viruses present in these patients that may initiate its development; (d) the abnormalities of the muscle layer that may be responsible for the dilation of the body of the esophagus that ultimately causes the sigmoid-like esophagus in the very last phase of this disease. This progression to the end-stage phase tends to occur in about 5% of patients. And, (e) the chronic inflammatory abnormalities in the squamous mucosa that may be the cause of the dysplastic and neoplastic changes that may lead to squamous cell carcinoma whose incidence in this disease is increased. These mucosal abnormalities are usually present in patients with markedly dilated body of the esophagus and severe food stasis.
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20
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Abstract
AbstractBornaviruses cause neurologic diseases in several species of birds, especially parrots, waterfowl and finches. The characteristic lesions observed in these birds include encephalitis and gross dilatation of the anterior stomach — the proventriculus. The disease is thus known as proventricular dilatation disease (PDD). PDD is characterized by extreme proventricular dilatation, blockage of the passage of digesta and consequent death by starvation. There are few clinical resemblances between this and the bornaviral encephalitides observed in mammals. Nevertheless, there are common virus-induced pathogenic pathways shared across this disease spectrum that are explored in this review. Additionally, a review of the literature relating to gastroparesis in humans and the control of gastric mobility in mammals and birds points to several plausible mechanisms by which bornaviral infection may result in extreme proventricular dilatation.
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21
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Goldstein AM, Thapar N, Karunaratne TB, De Giorgio R. Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment. Dev Biol 2016; 417:217-28. [PMID: 27059882 DOI: 10.1016/j.ydbio.2016.03.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.
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Affiliation(s)
- Allan M Goldstein
- Department of Pediatric Surgery, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| | - Tennekoon Buddhika Karunaratne
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
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22
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Abstract
Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy.
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Affiliation(s)
- Joseph T Krill
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
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23
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Sodikoff JB, Lo AA, Shetuni BB, Kahrilas PJ, Yang GY, Pandolfino JE. Histopathologic patterns among achalasia subtypes. Neurogastroenterol Motil 2016; 28:139-45. [PMID: 26542087 PMCID: PMC4688144 DOI: 10.1111/nmo.12711] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/24/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Achalasia has three distinct manometric phenotypes. This study aimed to determine if there were corresponding histopathologic patterns. METHODS We retrospectively examined surgical muscularis propria biopsies obtained from 46 patients during laparoscopic esophagomyotomy. Pre-operative (conventional) manometry tracings were reviewed by two expert gastroenterologists who categorized patients into Chicago Classification subtypes. Pathology specimens were graded on degree of neuronal loss, inflammation, fibrosis, and muscle changes. KEY RESULTS Manometry studies were categorized as follows: type I (n = 20), type II (n = 20), type III (n = 3), and esophagogastric junction outflow obstruction (EGJOO) (n = 3). On histopathology, complete ganglion cell loss occurred in 74% of specimens, inflammation in 17%, fibrosis in 11%, and muscle atrophy in 2%. Comparing type I and type II specimens, there was a statistically significant greater proportion of type I specimens with aganglionosis (19/20 vs 13/20, p = 0.044) and a statistically significant greater degree of ganglion cell loss in type I specimens (Wilcoxon Rank-Sum, p = 0.016). CD3(+) /CD8(+) cytotoxic T cells represented the predominant inflammatory infiltrate on immunohistochemistry. Three patients had completely normal appearing tissue (1 each in type II, type III, EGJOO). CONCLUSIONS & INFERENCES The greater degree, but similar pattern, of ganglion cell loss observed in type I compared to type II achalasia specimens suggests that type I achalasia represents a progression from type II achalasia. The spectrum of histopathologic findings - from complete neuronal loss to lymphocytic inflammation to apparently normal histopathology - emphasizes that 'achalasia' represents a pathogenically heterogeneous patient group with the commonality being EGJ outflow obstruction.
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Affiliation(s)
- Jamie B Sodikoff
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
| | - Amy A Lo
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
| | - Brandon B Shetuni
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
| | - Peter J Kahrilas
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
| | - John E Pandolfino
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611
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24
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Abstract
Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.
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Affiliation(s)
| | - Hannah P Kim
- Department of Internal Medicine, Nashville, TN, USA
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
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25
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Ates F, Vaezi MF, Fox M, Gyawali CP, Roman S, Smout AJPM, Pandolfino JE. The Pathogenesis and Management of Achalasia: Current Status and Future Directions. Gut Liver 2015; 9:449-63. [PMID: 26087861 PMCID: PMC4477988 DOI: 10.5009/gnl14446] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.
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Affiliation(s)
| | - Michael F. Vaezi
- Correspondence to: Michael F. Vaezi, Division of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN, Nashville, TN 37232, USA, Tel: +1-615-322-3739, Fax: +1-615-322-8525, E-mail:
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Achalasia--An Autoimmune Inflammatory Disease: A Cross-Sectional Study. J Immunol Res 2015; 2015:729217. [PMID: 26078981 PMCID: PMC4452860 DOI: 10.1155/2015/729217] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/24/2015] [Accepted: 04/14/2015] [Indexed: 02/08/2023] Open
Abstract
Idiopathic achalasia is a disease of unknown etiology. The loss of myenteric plexus associated with inflammatory infiltrates and autoantibodies support the hypothesis of an autoimmune mechanism. Thirty-two patients diagnosed by high-resolution manometry with achalasia were included. Twenty-six specimens from lower esophageal sphincter muscle were compared with 5 esophagectomy biopsies (control). Immunohistochemical (biopsies) and flow cytometry (peripheral blood) analyses were performed. Circulating anti-myenteric autoantibodies were evaluated by indirect immunofluorescence. Herpes simplex virus-1 (HSV-1) infection was determined by in situ hybridization, RT-PCR, and immunohistochemistry. Histopathological analysis showed capillaritis (51%), plexitis (23%), nerve hypertrophy (16%), venulitis (7%), and fibrosis (3%). Achalasia tissue exhibited an increase in the expression of proteins involved in extracellular matrix turnover, apoptosis, proinflammatory and profibrogenic cytokines, and Tregs and Bregs versus controls (P < 0.001). Circulating Th22/Th17/Th2/Th1 percentage showed a significant increase versus healthy donors (P < 0.01). Type III achalasia patients exhibited the highest inflammatory response versus types I and II. Prevalence of both anti-myenteric antibodies and HSV-1 infection in achalasia patients was 100% versus 0% in controls. Our results suggest that achalasia is a disease with an important local and systemic inflammatory autoimmune component, associated with the presence of specific anti-myenteric autoantibodies, as well as HSV-1 infection.
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Groneberg D, Zizer E, Lies B, Seidler B, Saur D, Wagner M, Friebe A. Dominant role of interstitial cells of Cajal in nitrergic relaxation of murine lower oesophageal sphincter. J Physiol 2014; 593:403-14. [PMID: 25630261 DOI: 10.1113/jphysiol.2014.273540] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 10/24/2014] [Indexed: 12/20/2022] Open
Abstract
Oesophageal achalasia is a disease known to result from reduced relaxation of the lower oesophageal sphincter (LES). Nitric oxide (NO) is one of the main inhibitory transmitters. NO-sensitive guanylyl cyclase (NO-GC) acts as the key target of NO and, by the generation of cGMP, mediates nitrergic relaxation in the LES. To date, the exact mechanism of nitrergic LES relaxation is still insufficiently elucidated. To clarify the role of NO-GC in LES relaxation, we used cell-specific knockout (KO) mouse lines for NO-GC. These include mice lacking NO-GC in smooth muscle cells (SMC-GCKO), in interstitial cells of Cajal (ICC-GCKO) and in both SMC/ICC (SMC/ICC-GCKO). We applied oesophageal manometry to study the functionality of LES in vivo. Isometric force studies were performed to monitor LES responsiveness to exogenous NO and electric field stimulation of intrinsic nerves in vitro. Cell-specific expression/deletion of NO-GC was monitored by immunohistochemistry. Swallowing-induced LES relaxation is strongly reduced by deletion of NO-GC in ICC. Basal LES tone is affected by NO-GC deletion in either SMC or ICC. Lack of NO-GC in both cells leads to a complete interruption of NO-induced relaxation and, therefore, to an achalasia-like phenotype similar to that seen in global GCKO mice. Our data indicate that regulation of basal LES tone is based on a dual mechanism mediated by NO-GC in SMC and ICC whereas swallow-induced LES relaxation is mainly regulated by nitrergic mechanisms in ICC.
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Affiliation(s)
- Dieter Groneberg
- Physiologisches Institut I, Universität Würzburg, Würzburg, Germany
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Noe E, Tabeling C, Doehn JM, Naujoks J, Opitz B, Hippenstiel S, Witzenrath M, Klopfleisch R. Juvenile megaesophagus in PKCα-deficient mice is associated with an increase in the segment of the distal esophagus lined by smooth muscle cells. Ann Anat 2014; 196:365-71. [DOI: 10.1016/j.aanat.2014.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/31/2014] [Accepted: 04/01/2014] [Indexed: 12/29/2022]
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Latiano A, Palmieri O, Bossa F, Latiano T, Corritore G, De Santo E, Martino G, Merla A, Valvano MR, Cuttitta A, Mazza T, Annese V, Andriulli A. Impact of genetic polymorphisms on the pathogenesis of idiopathic achalasia: Association with IL33 gene variant. Hum Immunol 2014; 75:364-9. [DOI: 10.1016/j.humimm.2014.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 01/03/2014] [Accepted: 01/14/2014] [Indexed: 02/06/2023]
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Quidute ARP, Freitas EVD, Lima TGD, Feitosa AML, Santos JPD, Correia JW. Achalasia and thyroid disease: possible autoimmune connection? ACTA ACUST UNITED AC 2013; 56:677-82. [PMID: 23329193 DOI: 10.1590/s0004-27302012000900013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 10/02/2012] [Indexed: 02/14/2023]
Abstract
Many cases have been published showing a co-existence of autoimmune thyroid diseases (AITDs) and other autoimmune diseases. About a quarter of patients with achalasia have a concurrent thyroid disease, most commonly associated with hypothyroidism. Although relatively rare, the association of achalasia and hyperthyroidism requires attention. The physiopathology of Grave's Disease (GD) involves B- and T-mediator lymphocytes, which have an affinity for known thyroid antigens: thyroglobulin, thyroid-peroxidase, and thyrotrophin receptor. Currently, however, the real physiopathogenesis of achalasia continues to be unknown. Some important findings are suggestive of an autoimmune mechanism: significant infiltration of the myoenteric plexus by monocytes, presence of the class II-Human Histocompatibility Complex DQwl antigen and antibodies to myoenteric neurons. The present case reports a patient who, despite testing negative for Chagas' disease, had achalasia, progressed to developing significant wasting and worsening of his quality of life, was later diagnosed with hyperthyroidism. After endoscopic esophageal dilatation and radioiodine ablation of the thyroid gland, there was great improvement in the patient clinical condition.
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The management of esophageal achalasia: from diagnosis to surgical treatment. Updates Surg 2013; 66:23-9. [PMID: 23817763 DOI: 10.1007/s13304-013-0224-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 06/21/2013] [Indexed: 02/07/2023]
Abstract
The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.
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Gyawali CP, Bredenoord AJ, Conklin JL, Fox M, Pandolfino JE, Peters JH, Roman S, Staiano A, Vaezi MF. Evaluation of esophageal motor function in clinical practice. Neurogastroenterol Motil 2013; 25:99-133. [PMID: 23336590 DOI: 10.1111/nmo.12071] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.
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Affiliation(s)
- C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.
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Hoshino M, Omura N, Yano F, Tsuboi K, Kashiwagi H, Yanaga K. Immunohistochemical study of the muscularis externa of the esophagus in achalasia patients. Dis Esophagus 2013; 26:14-21. [PMID: 22309323 DOI: 10.1111/j.1442-2050.2011.01318.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The etiology of achalasia is believed to be the neuropathy associated with chronic inflammation of the nerve plexus, but the cause of plexus inflammation is unknown. The purpose of this study was to evaluate the pathophysiology of achalasia by examining the muscularis externa of the esophagus. We used the muscularis externa of the esophagus of 62 patients with achalasia (median 44 years, male : female 32:30) who underwent surgical treatment (achalasia group) and of 10 patients (median 65.5 years, male : female 9:1) who underwent esophagectomy for thoracic esophageal cancer (control group) to perform immunohistochemical staining with S-100, CD43, c-kit (CD117), n-NOS, vasoactive intestinal polypeptide (VIP), and ubiquitin. The cell counts that were positive for S-100, n-NOS, VIP, and ubiquitin were significantly lower in the achalasia group compared with the control group (P < 0.001, P= 0.001, P < 0.001, and P= 0.001, respectively). There were no statistically significant differences with respect to CD43 and c-kit staining (P= 0.586 and P= 0.209, respectively). In conclusion, the pathophysiology of achalasia is therefore considered to be an impaired production of NO and VIP, which both affect interstitial cell of Cajal and smooth muscles, and this impairment is therefore considered to play a role in the pathophysiology of achalasia.
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Affiliation(s)
- M Hoshino
- Department of Surgery, Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan.
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Torab FC, Hamchou M, Ionescu G, Al-Salem AH. Familial achalasia in children. Pediatr Surg Int 2012; 28:1229-33. [PMID: 23076455 DOI: 10.1007/s00383-012-3186-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 12/22/2022]
Abstract
Achalasia is rare in the pediatric age group and in most cases it is idiopathic with no family history. Familial achalasia is very rare. This report describes two families with achalasia: in one, six children were affected while in the other a brother and a sister had Allgrove's syndrome (triple-A syndrome consisting of achalasia, adrenal insufficiency, and alacrima). Familial achalasia suggests that it is hereditary and may be transmitted as an autosomal recessive trait. The management of achalasia in children is still controversial. With the recent advances in minimal invasive surgery, laparoscopic Heller's myotomy is the procedure of choice in the management of achalasia in children.
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Affiliation(s)
- Fawaz Chikh Torab
- Division of Pediatric Surgery, Department of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates.
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Ghoshal UC, Daschakraborty SB, Singh R. Pathogenesis of achalasia cardia. World J Gastroenterol 2012; 18:3050-7. [PMID: 22791940 PMCID: PMC3386318 DOI: 10.3748/wjg.v18.i24.3050] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Revised: 10/11/2011] [Accepted: 04/28/2012] [Indexed: 02/06/2023] Open
Abstract
Achalasia cardia is one of the common causes of motor dysphagia. Though the disease was first described more than 300 years ago, exact pathogenesis of this condition still remains enigmatic. Pathophysiologically, achalasia cardia is caused by loss of inhibitory ganglion in the myenteric plexus of the esophagus. In the initial stage, degeneration of inhibitory nerves in the esophagus results in unopposed action of excitatory neurotransmitters such as acetylcholine, resulting in high amplitude non-peristaltic contractions (vigorous achalasia); progressive loss of cholinergic neurons over time results in dilation and low amplitude simultaneous contractions in the esophageal body (classic achalasia). Since the initial description, several studies have attempted to explore initiating agents that may cause the disease, such as viral infection, other environmental factors, autoimmunity, and genetic factors. Though Chagas disease, which mimics achalasia, is caused by an infective agent, available evidence suggests that infection may not be an independent cause of primary achalasia. A genetic basis for achalasia is supported by reports showing occurrence of disease in monozygotic twins, siblings and other first-degree relatives and occurrence in association with other genetic diseases such as Down’s syndrome and Parkinson’s disease. Polymorphisms in genes encoding for nitric oxide synthase, receptors for vasoactive intestinal peptide, interleukin 23 and the ALADIN gene have been reported. However, studies on larger numbers of patients and controls from different ethnic groups are needed before definite conclusions can be obtained. Currently, the disease is believed to be multi-factorial, with autoimmune mechanisms triggered by infection in a genetically predisposed individual leading to degeneration of inhibitory ganglia in the wall of the esophagus.
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Savarino E, Gemignani L, Zentilin P, De Bortoli N, Malesci A, Mastracci L, Fiocca R, Savarino V. Achalasia with dense eosinophilic infiltrate responds to steroid therapy. Clin Gastroenterol Hepatol 2011; 9:1104-6. [PMID: 21839711 DOI: 10.1016/j.cgh.2011.08.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 07/26/2011] [Accepted: 08/02/2011] [Indexed: 12/13/2022]
Abstract
A patient presented with chronic substernal discomfort and intermittent dysphagia for solids. High-resolution impedance manometry (HRIM) of the esophagus showed that there was no peristalsis in the esophageal body but incomplete relaxation of the lower esophageal sphincter and incomplete bolus transit, so the patient was diagnosed with achalasia. Moreover, probably because of esophageal stasis, eosinophilic infiltration that mimicked a pattern of eosinophilic esophagitis was observed, on the basis of multiple biopsies of the esophagus. The patient was given 50 mg prednisolone once daily; the symptoms improved dramatically, and HRIM showed complete recovery of esophageal peristalsis, deeper relaxation of the lower esophageal sphincter, and complete bolus transit profile. HRIM can therefore be used to assess dysmotility abnormalities in patients with achalasia and eosinophilic-like esophagitis, and steroids relieve these symptoms. Treatment with a high dose of prednisolone resulted in a complete disappearance of dysphagia because of improved esophageal motility and reduced eosinophilic infiltrate. It is therefore important to control the inflammatory process in patients with idiopathic achalasia, which is likely to result from an autoimmune reaction.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy.
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Rivera LR, Poole DP, Thacker M, Furness JB. The involvement of nitric oxide synthase neurons in enteric neuropathies. Neurogastroenterol Motil 2011; 23:980-8. [PMID: 21895878 DOI: 10.1111/j.1365-2982.2011.01780.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nitric oxide (NO), produced by the neural nitric oxide synthase enzyme (nNOS) is a transmitter of inhibitory neurons supplying the muscle of the gastrointestinal tract. Transmission from these neurons is necessary for sphincter relaxation that allows the passage of gut contents, and also for relaxation of muscle during propulsive activity in the colon. There are deficiencies of transmission from NOS neurons to the lower esophageal sphincter in esophageal achalasia, to the pyloric sphincter in hypertrophic pyloric stenosis and to the internal anal sphincter in colonic achalasia. Deficits in NOS neurons are observed in two disorders in which colonic propulsion fails, Hirschsprung's disease and Chagas' disease. In addition, damage to NOS neurons occurs when there is stress to cells, in diabetes, resulting in gastroparesis, and following ischemia and reperfusion. A number of factors may contribute to the propensity of NOS neurons to be involved in enteric neuropathies. One of these is the failure of the neurons to maintain Ca(2+) homeostasis. In neurons in general, stress can increase cytoplasmic Ca(2+), causing a Ca(2+) toxicity. NOS neurons face the additional problem that NOS is activated by Ca(2+). This is hypothesized to produce an excess of NO, whose free radical properties can cause cell damage, which is exacerbated by peroxynitrite formed when NO reacts with oxygen free radicals.
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Affiliation(s)
- L R Rivera
- Department of Anatomy & Cell Biology, University of Melbourne, Victoria, Australia
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Bagheri R, Haghi SZ, Noorshafiee S. Surgical treatment of achalasia: transabdominal versus transthoracic cardiomyotomy. Ann Thorac Cardiovasc Surg 2011; 17:254-9. [PMID: 21697786 DOI: 10.5761/atcs.oa.09.01506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 05/27/2010] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Achalasia is a primary esophageal motor disorder involving the body of the esophagus and lower esophageal sphincter. The mechanism is destruction of the myenteric plexus after a viral infection. Multiple methods of treatment with variable results induced in achalasia. MATERIALS AND METHODS We analyzed 70 patients with achalasia that underwent surgical treatment with transabdominal or transthoracic cardiomyotomy from 1982 to 2008 in Mashhad (Ghaem and Omid) hospital and at least 2 years follow up for evaluated result of surgery. RESULTS The mean age was 39.2 ± 9.42 years and the M/F = 0.89. The most common symptom was dysphagia (100%). The interval between beginnings of symptoms to a definitive diagnosis was 10.6 ± 8.3 month. The ratio between the two techniques was 35/35 = 1. In 67.1% of patients, a previous history of pneumatic dilation was reported. Long-term good results after surgery were seen in 77.2% of patients. Recurrence after surgical treatment was seen in 22.8%. A comparison of the two techniques (with or without antireflux surgery), showed a greater failure rate in transabdominal cardiomyotomy without the antireflux protocol (8/15 = 40%), but by the chi- square test, the difference was not statistically significant (P = 0.107). The most common complication after surgery was esophageal leakage (2.85%), and mortality was zero. In recurrence, most patients underwent pneumatic dilation (9/16 = 56.2%), and if surgery was needed, all patients underwent a transthoracic approach with antireflux treatment. CONCLUSION Based on the good, long-term results with the surgical treatment of achalasia, surgery is recommended in most patients. A transthoracic or transabdominal approach had good, long-term results, but a transthoracic approach had better results and usually did not need antireflux surgery.
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Affiliation(s)
- Reza Bagheri
- Thoracic Surgery, Mashhad University of Medical Sciences, Ahmad Abad Street, Mashhad, Iran.
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Nuñez C, García-González MA, Santiago JL, Benito MS, Mearín F, de la Concha EG, de la Serna JP, de León AR, Urcelay E, Vigo AG. Association of IL10 promoter polymorphisms with idiopathic achalasia. Hum Immunol 2011; 72:749-52. [PMID: 21641950 DOI: 10.1016/j.humimm.2011.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 04/18/2011] [Accepted: 05/13/2011] [Indexed: 12/21/2022]
Abstract
Idiopathic achalasia is an esophageal motor disorder of unknown etiology. A wealth of evidence supports the concept that achalasia is an immune-mediated disease. According to this evidence, achalasia has been significantly associated with specific alleles of the human leukocyte antigen class II, PTPN22 and IL23R. Several studies have demonstrated association of the IL10 gene with different inflammatory disorders. Our aim was to evaluate the role of functional IL10 promoter polymorphisms in susceptibility to idiopathic achalasia. A case-control study was performed with the -1082, -819, and -592 IL10 promoter polymorphisms in 282 patients and 529 controls and in an independent replication set of 75 patients and 575 controls. The GCC haplotype of the IL10 promoter was reported to be associated with a lower risk of achalasia in the discovery sample (odds ratio [OR] = 0.79, 95% confidence interval [CI] = 0.64-0.98, p = 0.029). This association was validated in a replication set (OR = 0.69, 95% CI = 0.48-1.00, p = 0.04). In the combined analysis no heterogeneity was observed between the 2 sample sets and the GCC haplotype was significantly associated with the disease (OR(MH) = 0.76, 95% CI = 0.63-0.91, p = 0.003). Our results provide the first evidence for an association between IL10 promoter polymorphisms and idiopathic achalasia, suggesting that the interleukin-10 cytokine may contribute to the pathogenesis of this disease.
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Affiliation(s)
- Concepción Nuñez
- Clinical Immunology Department, Instituto de Investigación Sanitaria San Carlos, Madrid, Spain
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Distal contraction latency: a measure of propagation velocity optimized for esophageal pressure topography studies. Am J Gastroenterol 2011; 106:443-51. [PMID: 20978487 PMCID: PMC3049837 DOI: 10.1038/ajg.2010.414] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES A defining feature of peristalsis is propagation velocity, which determines the timing of the distal contraction relative to the swallow. This study aimed to exploit a coordinate-based strategy to quantify the normal latency of the distal esophageal contraction as a measure of propagation velocity optimized for high-resolution esophageal pressure topography (EPT) studies. METHODS EPT studies for 75 healthy volunteers were merged in a computer simulation. Swallows were synchronized and analyzed as a 100 × 200 pixel grid that normalized esophageal length from the pharynx to the stomach for a 20-s period to first calculate a composite for each individual and then to establish normative values for the morphology and latency of the distal contraction among individuals. RESULTS Stereotyped landmarks in composite EPT studies were pressure troughs in the proximal and distal esophagus isolating the distal segment and the contractile deceleration point (CDP) localizing the termination of peristalsis in the distal segment. Distal contractile latency was timed to the CDP (median 6.0 s, 95% confidence interval 4.8-7.6 s) and to lower esophageal sphincter (LES) contraction (median 9.2 s, 95% confidence interval 6.5-11.5 s). Illustrative examples are shown of rapidly conducted contractions with normal or short latency, suggesting short latency to be the preferable EPT metric of rapid propagation. CONCLUSIONS The proposed scheme, utilizing the topographic coordinates of contraction relative to the swallow as an alternative to conventional measures of peristaltic velocity, lays the foundation for a physiologically grounded classification of peristaltic abnormalities in EPT. Future studies will test the clinical utility of this scheme.
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Porter RF, Gyawali CP. Botulinum toxin injection in dysphagia syndromes with preserved esophageal peristalsis and incomplete lower esophageal sphincter relaxation. Neurogastroenterol Motil 2011; 23:139-44, e27-8. [PMID: 20939855 DOI: 10.1111/j.1365-2982.2010.01604.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Botulinum toxin injection into the lower esophageal sphincter (LES) treats dysphagia syndromes with preserved peristalsis and incomplete LES relaxation (LESR). We evaluated clinical and esophageal motor characteristics predicting response, and compared duration of efficacy to similarly treated achalasia patients. METHODS Thirty-six subjects (59 ± 2.2 years, 19F/17M) with incomplete LESR on high resolution manometry (HRM) treated with botulinum toxin injection were identified. Individual and composite symptom indices were calculated, and HRM characteristics extracted. Symptom resolution for 6 months was a primary outcome measure, and repeat botulinum toxin injection, dysphagia recurrence or employment of alternate therapeutic approaches were secondary outcome measures. Duration of response was compared using Kaplan-Meier survival curves to a historical cohort of similarly treated achalasia subjects. KEY RESULTS Response lasted a mean of 12.8 ± 2.3 months. Symptom relief for >6 months was seen in 58.3%; short (<6 months) response was associated with younger age, higher chest pain index, and esophageal body spastic features (P ≤ 0.04). On multivariate logistic regression, chest pain, younger age and contraction amplitudes >180 mmHg independently predicted <6 months relief (P < 0.05 for each). On survival analysis, relief with a single injection extended to 1 year in 54.8% and 1.5 years in 49.8%, statistically equivalent to that reported by 42 similarly treated achalasia subjects (59 ± 3.2 years, 24F/18M). Symptom relief was more prolonged compared to achalasia when repeat injections were performed on demand (P = 0.003). CONCLUSIONS & INFERENCES Botulinum toxin injections can provide lasting symptom relief in dysphagia syndromes with incomplete LESR. Prominent perceptive symptoms and non-specific spastic features may predict shorter relief.
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Affiliation(s)
- R F Porter
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Figueroa JJ, Engelstad JK, Spinner RJ, Dyck PJB. Immune trigeminal sensory neuropathy with esophageal achalasia: Improvement with long-term immunotherapy. Muscle Nerve 2011; 43:289-93. [DOI: 10.1002/mus.21889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ganem D, Kistler A, DeRisi J. Achalasia and viral infection: new insights from veterinary medicine. Sci Transl Med 2010; 2:33ps24. [PMID: 20505212 DOI: 10.1126/scitranslmed.3000986] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Achalasia is a serious disorder in which the movement of food and liquids through the esophagus is impaired. It is currently thought to be caused by an inflammatory process that destroys neurons in myenteric ganglia, which affect peristalsis in the esophagus. The factor(s) that precipitate this inflammatory process are unknown; possibilities include environmental agents (such as microbes or toxins) and/or cell-mediated autoimmune reactivity. Recently, infection with a newly described bornavirus has been strongly linked to a disease of exotic birds that displays many striking similarities to achalasia. These findings demonstrate that viruses can induce achalasia-like pathophysiology and have renewed interest in the search for infectious agents in this enigmatic human disease.
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Affiliation(s)
- Don Ganem
- Department of Medicine, University of California, San Francisco, CA 94143, USA.
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Gockel HR, Schumacher J, Gockel I, Lang H, Haaf T, Nöthen MM. Achalasia: will genetic studies provide insights? Hum Genet 2010. [PMID: 20700745 DOI: 10.1007/s00439-010-0874-8.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite increasing understanding of the pathophysiology of achalasia, the etiology of this esophageal motility disorder remains largely unknown. However, the occurrence of familial achalasia and its association with well-defined genetic syndromes suggest the involvement of genetic factors. Mutant mouse models display gastrointestinal disturbances that are similar to those observed in achalasia patients. The candidate gene approach has revealed some promising results; however, it has not established conclusive links to specific genes so far. The aim of this review was to summarize current knowledge of the genetics of achalasia. We also discuss the extent to which our understanding of achalasia is likely to be enhanced through future molecular genetic research.
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Affiliation(s)
- Henning R Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
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Gockel HR, Schumacher J, Gockel I, Lang H, Haaf T, Nöthen MM. Achalasia: will genetic studies provide insights? Hum Genet 2010; 128:353-64. [PMID: 20700745 DOI: 10.1007/s00439-010-0874-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 08/02/2010] [Indexed: 12/15/2022]
Abstract
Despite increasing understanding of the pathophysiology of achalasia, the etiology of this esophageal motility disorder remains largely unknown. However, the occurrence of familial achalasia and its association with well-defined genetic syndromes suggest the involvement of genetic factors. Mutant mouse models display gastrointestinal disturbances that are similar to those observed in achalasia patients. The candidate gene approach has revealed some promising results; however, it has not established conclusive links to specific genes so far. The aim of this review was to summarize current knowledge of the genetics of achalasia. We also discuss the extent to which our understanding of achalasia is likely to be enhanced through future molecular genetic research.
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Affiliation(s)
- Henning R Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
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de León AR, de la Serna JP, Santiago JL, Sevilla C, Fernández-Arquero M, de la Concha EG, Nuñez C, Urcelay E, Vigo AG. Association between idiopathic achalasia and IL23R gene. Neurogastroenterol Motil 2010; 22:734-8, e218. [PMID: 20367798 DOI: 10.1111/j.1365-2982.2010.01497.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Idiopathic achalasia is a primary esophageal motor disorder of unknown etiology. Different evidences have been reported in support of achalasia as the result of an autoimmune and inflammatory process leading to neuronal cell loss. According to this, idiopathic achalasia has been significantly associated with specific alleles of the human leukocyte antigen system class II, although few reports studying association with other loci can be found in the literature. Recent studies have shown association of a non-synonymous polymorphism within the IL23R gene with different chronic inflammatory disorders, including Barrett's esophagus. The purpose of this study was to assess whether the IL23R coding variant Arg381Gln polymorphism is involved in susceptibility to idiopathic achalasia. METHODS We performed a case-control study including 262 patients with idiopathic achalasia and 802 healthy subjects, all of them white Spaniards. Achalasia patients were diagnosed on the basis of clinical, radiographic, endoscopic, and manometric criteria. All samples were genotyped for the IL23R Arg381Gln polymorphism using TaqMan technology. KEY RESULTS The minor allele of the Arg381Gln polymorphism was significantly increased in patients compared with healthy controls (OR = 1.46, 95% CI = 1.01-2.11, P = 0.036). This association seems to be specific to male patients with disease onset after 40 years (OR = 2.33, 95% CI = 1.29-4.16, P = 0.002). CONCLUSIONS & INFERENCES Our results suggest a role of IL23R in idiopathic achalasia predisposition and extend the evidence of the general influence of this gene in autoimmune and inflammatory diseases.
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Affiliation(s)
- A R de León
- Gastroenterology Department, Hospital Clínico San Carlos, Madrid, Spain
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Abstract
BACKGROUND Achalasia is a primary esophageal motor disorder characterized by degenerative changes of the myenteric plexus. The pathophysiologic abnormalities may be the final result of several intermeshing mechanisms, and more than one single factor may cause the motor abnormalities. AIMS To report our experience in investigating the myenteric plexus of achalasia patients undergoing esophagomyotomy. PATIENTS AND METHODS Tissue samples from 12 patients undergoing Heller myotomy for achalasia were evaluated and compared with esophageal tissue specimens from 7 controls. Enteric neurons and interstitial cells of Cajal (ICC) were assessed by immunohistochemical methods, and the presence of vasoactive intestinal polypeptide ergic fibers and of CD3 lymphocytes. The possible presence of herpesvirus was also assessed by immunohistochemistry, whereas that of papillomavirus was assessed by in-situ hybridization. RESULTS Compared with controls, achalasia patients displayed a significant decrease of both enteric neurons and ICC. Immunoreactivity for vasoactive intestinal polypeptide was completely absent in each patient. CD3 staining disclosed myenteric plexitis in 5 (42%) patients; no control patient had plexitis. All patients were completely negative for the presence of both herpes simplex virus and human papillomavirus. CONCLUSIONS The enteric nervous system of the lower esophageal sphincter area is impaired in patients with "idiopathic achalasia," and the abnormalities involve ICC and neurons in many patients. The triggering factors for these abnormalities are, however, still unknown.
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Veress B, Nyberg B, Törnblom H, Lindberg G. Intestinal lymphocytic epithelioganglionitis: a unique combination of inflammation in bowel dysmotility: a histopathological and immunohistochemical analysis of 28 cases. Histopathology 2009; 54:539-49. [PMID: 19413636 DOI: 10.1111/j.1365-2559.2009.03265.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Visceral inflammatory neuropathies are enteric disorders underlying various forms of bowel dysmotility. The aim was to analyse the microscopic characteristics of a unique combination of intraepithelial lymphocytosis and myenteric ganglioneuritis. METHODS AND RESULTS Paraffin sections of full-thickness proximal jejunal biopsy specimens from 28 patients, with proven disorders of gastrointestinal motility, were analysed following conventional and immunohistochemical staining. Serial transversal and tangential sectioning visualized large myenteric plexus areas. Between 1993 and 2005, 28 patients with inflammatory neuropathy (25 female and three male) showed this combination of lymphocytic infiltration. Two of the patients also had coeliac disease. The mean number of intraepithelial CD3+ lymphocytes was 36 per 100 epithelial cells (range 27-68; upper normal limit 25 lymphocytes). There was myenteric ganglionitis of variable severity (mean 4.6 myenteric lymphocytes per ganglion; upper normal limit two lymphocytes) with cytotoxic T-cell predominance. Myenteric neurons showed signs of degeneration and an abnormal immunohistological pattern. Hyperplasia and hypertrophy of Cajal cells were observed. The longitudinal muscle layer was thickened in many cases. CONCLUSIONS A subset of patients with gastrointestinal motility disorders exhibit the combination of intraepithelial lymphocytosis and myenteric ganglionitis in full thickness biopsy specimens of the small bowel. We suggest calling this entity 'intestinal lymphocytic epithelioganglionitis'.
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Affiliation(s)
- Béla Veress
- Department of Clinical Pathology and Cytology, University Hospital MAS, Lund University, Malmö, Sweden
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Madureira FA, Madureira FA, Loss AB, Madureira D. Qualidade de vida após a cardiomiotomia à Heller-Dor. Rev Col Bras Cir 2009. [DOI: 10.1590/s0100-69912009000300003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVOS: Avaliar os resultados da cardiomiotomia de Heller associada à fundoplicatura de Dor por Laparoscopia (HDL) no tratamento cirúrgico da acalásia do esôfago, através de escores de qualidade de vida e dados da esofagomanometria. MÉTODOS: Foram estudados retrospectivamente 60 pacientes operados por acalasia do cárdia, de 2001 a 2007, sendo analisadas no pré-operatório as características desta população e os resultados das provas diagnósticas. Aplicamos um escore de disfagia e de qualidade de vida no pré e pós-operatório e realizamos o estudo do comportamento da pressão do esfíncter esofageano inferior (Peei) no pré e pós operatório de todos os pacientes. RESULTADOS: Eram 37 do sexo feminino e 23 do masculino. A idade média foi 41,08 anos(12 a 87). Não houve mortalidade cirúrgica, nem conversões. Tempo médio de início da dieta foi de 1,6 dias. Considerado resultado excelente em 80% da série, resultados intermediários em 20%. A média do escore de disfagia no pré operatório foi de 9,03 pontos e a média de pós, foi de 1,7 pontos (máximo de 10 pontos), p=0,0001, sendo observada queda entre pré e pós-operatório de 7,33 pontos, 81,17%. A média da Peei no pré-operatório foi de 32,41 mmhg e no pós 12,7 mmhg. CONCLUSÃO: A cirurgia HDL é procedimento seguro de ser realizado e apresentou bons resultados, sendo capaz de modificar os escores de qualidade de vida subjetivos, e os dados objetivos da Peei, de forma significativa.
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