Reversible achalasia due to reticulum-cell sarcoma

Laparoscopic diagnosis of pleural mesothelioma presenting with pseudoachalasia

Pseudoachalasia due to pleural mesothelioma is an extremely rare condition. A 70-year-old woman presented with progressive dysphagia for solid and liquids and a mild weight loss. A barium swallow study revealed an esophageal dilatation and a smoothly narrowed esophagogastric junction. An esophageal manometry showed absence of peristalsis. Endoscopy demonstrated an extrinsic stenosis of the distal esophagus with negative biopsies. A marked thickening of the distal esophagus and a right-sided pleural effusion were evident at computed tomography (CT) scan, but cytological examination of the thoracic fluid was negative. Endoscopic ultrasound showed the disappearance of the distal esophageal wall stratification and thickening of the esophageal wall. The patient underwent an explorative laparoscopy. Biopsies of the esophageal muscle were consistent with the diagnosis of epithelioid type pleural mesothelioma. An esophageal stent was placed for palliation of dysphagia. The patient died four months after the diagnosis. This is the first reported case of pleural mesothelioma diagnosed through laparoscopy.

Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair

BACKGROUND

Benign esophageal pseudoachalasia is a rare condition.

DISCUSSION

We report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented.

RESULTS

Endoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen's wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.

Pseudoachalasia: not only esophago-gastric cancer

Pseudoachalasia is a rare clinical entity which has clinical, radiographic and manometric features often indistinguishable from achalasia. A small primary adenocarcinoma arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes. Rarely, processes other than esophagogastric cancers may lead to the development of pseudoachalasia. We present three cases of pseudoachalasia in which the primary cause of the disease was not an esophagogastric cancer. The causes were a pancreatic carcinoma, a breast cancer and an histiocytosis X. Aspects of these three patients' diagnostic and therapeutic course are discussed in detail.

Pseudoachalasia: a case series and analysis of the literature

OBJECTIVE

Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus.

MATERIAL AND METHODS

Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect.

RESULTS

In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologic examination of the esophagus proved to be of little value in distinguishing between the diseases. In the majority of cases only surgical exploration revealed the underlying cause. A coincidence of primary achalasia and disorders of the gastroesophageal junction was excluded by showing return of peristalsis following treatment. The analysis of the literature showed a total of 264 cases of pseudoachalasia in 122 publications. Most cases of were due to malignant disease (53.9% primary and 14.9% secondary malignancy), followed by benign lesions (12.6%) and sequelae of surgical procedures at the distal esophagus or proximal stomach (11.9%). In rare instances, the disease was an expression of a paraneoplastic process due to distant neuronal involvement rather than to local invasion with destruction of the myenteric plexus (2.6%).

CONCLUSIONS

The diagnosis of pseudoachalasia is difficult to establish by conventional diagnostic measures. The main distinguishing feature of secondary versus primary achalasia is the complete reversal of pathologic motor phenomena following successful therapy of the underlying disorder.

Pseudoachalasia caused by pancreatic carcinoma

Secondary achalasia or pseudoachalasia is mostly caused by gastric or oesophageal carcinoma. Here we report a case of pseudoachalasia caused by a pancreatic tumour invading the cardiac region. A 66-year-old man with a 2-month history of dysphagia and weight loss showed no abnormalities on upper gastrointestinal endoscopy and computed tomography scan, but had no swallow-induced relaxation on oesophageal manometry. Based on the patient's history and oesophageal manometry findings, further investigation was performed to exclude pseudoachalasia. Endoscopic ultrasonography showed abnormalities in the cardiac region, but large endoscopic biopsies showed no malignancy. A laparotomy was performed, which revealed a large, irresectable tumour originating from the pancreatic corpus region and expanding into the gastric cardia region. This case illustrates that a pancreatic tumour invading the cardiac region may present as pseudoachalasia.

Association of pseudoachalasia with advancing cancer of the gastric cardia

BACKGROUND

Pseudoachalasia is attributable to malignant tumors of the gastric cardia in more than 50% of cases. Study of the progression of esophageal manometric abnormalities with increasing tumorous involvement of the esophagogastric junction may improve our understanding of the pathophysiologic characteristics of pseudoachalasia.

METHODS

During a 2-year period, esophageal manometric characteristics were evaluated for 17 of 21 consecutive patients with cancer of the gastric cardia. Manometry was not possible in the other four. Manometric parameters assessed included lower esophageal sphincter pressure, percentage lower esophageal sphincter relaxation, and percentage failed peristalsis. The extent of malignant involvement of the esophagogastric junction was graded as none, less than 50% of the circumference, or 50% or more of the circumference, assessed from surgical specimens in 13 cases and endoscopy in 4 cases.

RESULTS

Pseudoachalasia was diagnosed in 3 cases, all with 50% or greater circumferential involvement of the esophagogastric junction. The first manometric indication of evolving pseudoachalasia was impaired lower esophageal sphincter relaxation; loss of peristaltic function was a secondary consequence.

CONCLUSIONS

These findings suggest that the primary mechanism of pseudoachalasia with gastric cardia cancer is malignant stenosis of the esophagogastric junction.

Clinical presentation and evaluation of malignant pseudoachalasia

Malignant pseudoachalasia can be indistinguishable from primary achalasia on routine clinical evaluation, often resulting in a delay in diagnosis. To better define the clinical features and appropriate management of this disease, the course of five patients discovered to have pseudoachalasia after being referred for a minimally invasive Heller myotomy was reviewed, as were 67 cases of pseudoachalasia previously reported in the literature. Patients with an occult malignancy tended to present with shorter durations of symptoms, greater weight loss, and at a more advanced age than patients with primary achalasia. Since contrast radiography and endoscopy frequently failed to differentiate these two diseases, persons with presumed achalasia meeting these criteria who are referred for minimally invasive surgery should undergo additional imaging to rule out an occult malignancy, since this condition cannot be reliably detected during the course of a thoracoscopic or laparoscopic esophagomyotomy.

Isolated primary oesophageal involvement by lymphoma: a rare cause of dysphagia: two case histories and a review of other published data

Primary oesophageal involvement by lymphoma in two patients, one with Hodgkin's disease and one with non-Hodgkin's lymphoma is reported. In both, there were no manifestations of the disease outside the oesophagus, which is exceptionally rare. In the patient with non-Hodgkin's lymphoma, the oesophageal tumour was the first manifestation of lymphoma. Shortly after admission he developed a tracheo-oesophageal fistula from which he died before treatment could be started. In the patient with Hodgkin's disease, isolated oesophageal lymphoma was the first relapse after a 13 year interval free of disease. As he had previously received mediastinal irradiation he was treated with combination chemotherapy that resulted in long term survival (> five years). Several other long term survivors have been described but only after radiotherapy or surgery. These findings suggest that systemic chemotherapy may be equally successful in treating isolated primary oesophageal lymphoma, thus offering an alternative for those patients in whom local treatment is contraindicated.

Achalasia, diffuse spasm and non-specific motor disorders

Achalasia is the best understood of the motor disorders described in this chapter. The pathogenesis involves loss of intramural neurones, a process that subsequently results in poor lower sphincter relaxation and atony of the oesophageal body. Treatment is appropriately focused on mechanical or pharmacological alleviation of LOS obstruction. In contrast, the pathophysiology of DOS and the non-specific disorders remains poorly understood. Some of the non-specific disorders, such as the vigorous contraction wave abnormalities (including 'nutcracker oesophagus'), appear closely related to DOS. Treatment for patients with these findings has been based on assumptions about mechanisms of symptom production. The non-specific disorders are common in referred patients with oesophageal symptoms, and the importance of these findings deserves further study. We use a method for categorization of these manometric abnormalities which aids understanding of this difficult area and recommend its more widespread use.

Esophageal achalasia secondary to mesothelioma

Achalasia secondary to malignancy is rare, with most cases associated with gastric adenocarcinoma of the gastroesophageal junction. This report describes the clinicopathologic features of a 64-year-old man found to have mesothelioma as the cause of secondary achalasia. To our knowledge, this is the first case of secondary achalasia produced by a mesothelioma. We reviewed the English literature in regard to achalasia induced by tumors.

Severe destruction of esophageal nerves in a patient with achalasia secondary to gastric cancer. A possible role of eosinophil neurotoxic proteins

We present a case of secondary achalasia due to an adenocarcinoma of the stomach with no tumor infiltration of the esophagus. Immunohistochemical staining revealed a massive infiltration of activated eosinophils in the muscularis of the esophagus with secretion of the highly cytotoxic and neurotoxic eosinophil cationic protein (ECP). Immunohistochemical staining for the neuropeptides VIP and substance P, as well as the histochemical demonstration of AChE, revealed a nearly total absence of all three neurotransmitters/modulators compared to control. The hypothesis is advanced that eosinophil neurotoxicity is the cause of secondary achalasia.

Pancreatic pseudocyst as a cause for secondary achalasia

Secondary achalasia is commonly due to cancer. Benign causes are rare and an association with pancreatitis has never been made. Our patient presented with clinical, manometric, endoscopic, and radiographic features of achalasia that occurred in conjunction with a pancreatic pseudocyst extending into the mediastinum. Documentation of this unique relationship was made on two occasions after episodes of complicated pancreatitis and was confirmed by restoration of normal esophageal function after drainage of the pseudocyst. Onset of dysphagia occurring in association with pancreatitis suggests the presence of a pseudocyst and secondary achalasia.

Esophageal achalasia syndromes

Esophageal achalasia, characterized by failure of the lower esophageal sphincter to relax normally with swallowing and esophageal aperistalsis, may be primary or secondary to another disorder (in the United States most often cancer). Primary achalasia is of unclear etiology but almost certainly is a disorder of the innervation of the smooth muscle portion of the esophagus. This article reviews the classification and clinical features of achalasia syndromes, as well as current concepts of pathogenesis, diagnosis, complications, and therapy of this group of disorders.

Secondary neoplasms of the esophagus

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.

Comparison of pseudoachalasia and achalasia

Malignancies involving the gastric cardia or distal esophagus can result in a clinical syndrome termed pseudoachalasisa that mimics idiopathic achalasia. If not promptly recognized, pseudoachalasia can result in inappropriate pneumatic dilatation of the lower esophageal sphincter segment and delay appropriate treatment of the underlying malignancy. During the past 14 years, six patients with pseudoachalasia and 161 patients with primary idiopathic achalasia were encountered. Pseudoachalasia occurred mainly in the elderly and represented about 9 percent of these patients over 60 years of age with suspected achalasia. Five of the six pseudoachalasia cases were secondary to adenocarcinoma that originated in the gastric fundus, and one was caused by a squamous cell carcinoma of the distal esophagus. Conventional esophageal manometry did not discriminate achalasia from pseudoachalasia. On the other hand, esophagogastroscopy with biopsy resulted in a diagnosis of pseudoachalasia in five of these cases and in 24 of 32 cases reported previously. Ominous endoscopic findings are mucosal ulceration or nodularity, reduced compliance of the esophagogastric junction, or an inability to pass the endoscope into the stomach. Radiographic evaluation, particularly in conjunction with amyl nitrite inhalation, was also useful in discriminating pseudoachalasia from primary achalasia. It is concluded that pseudoachalasia generally mimics idiopathic achalasia imperfectly and can usually be diagnosed prior to surgery by fastidious endoscopic and radiographic examination.

Achalasia secondary to nongastrointestinal malignancies

Secondary or "pseudo" achalasia of the esophagus can mimic idiopathic achalasia radiographically and can be difficult to diagnose. Typically, it is due to invasive carcinoma involving the gastroesophageal junction, usually gastric adenocarcinoma. Occasionally, an achalasialike condition can be produced by tumors not involving the gastroesophageal junction. We report 2 cases, 1 of lung carcinoma and the other of hepatoma, in which the patients had radiographic and endoscopic changes compatible with achalasia. However, the onset of symptoms was abrupt and the patients were elderly; these are unusual features for primary achalasia. There have been several other reports of nongastrointestinal neoplasms producing a clinical and radiographic picture similar to achalasia. Although there are several theories as to the cause, our cases would support the concept that direct tumor involvement of the gastroesophageal junction is not necessary to produce significant esophageal dysmotility.

Failure of clinical criteria to distinguish between primary achalasia and achalasia secondary to tumor

Three clinical criteria have been reported to distinguish patients with primary achalasia from patients with achalasia secondary to tumor invasion of the gastroesophageal junction. These criteria (age greater than 50 years, duration of symptoms less than one year, and weight loss greater than 15 pounds) are important because of their potential use for deciding between pneumatic dilation and exploratory surgery. In the present investigation we assessed the frequency of these criteria alone and in combination in 79 patients with primary and in two patients with secondary achalasia seen at our institution over a 9 1/2-year period. Our results indicate that while these criteria are highly sensitive and moderately specific, their predictive value for distinguishing secondary achalasia from primary achalasia is exceedingly low. For this reason, early exploratory surgery is not indicated in patients with newly diagnosed achalasia who meet these criteria unless there is prior radiologic or endoscopic evidence for tumor.

Central nervous system lymphoma presenting as dysphagia

Two patients are presented having lymphomatous involvement of the central nervous system in whom dysphagia was the predominant symptom. All indicated studies failed to reveal evidence of direct esophageal involvement, and the dysphagia improved during treatment of the neural component. Esophageal manometric studies revealed abnormalities of the striated muscle portion of the esophagus. These two case histories suggest that invasion of the central nervous system with lymphoma may produce abnormalities of the neuromuscular control of esophageal function resulting in dysphagia.

Return of esophageal peristalsis in achalasia secondary to gastric cancer

A 69-year-old white man developed progressive symptoms of dysphagia for solids and liquids and regurgitation of undigested food accompanied by a 12-kg weight loss over a 4-month period. Initially, radiographs of the esophagus and stomach were normal, but when repeated 4 months later, a diagnosis of achalasia was suggested. Esophageal manometry performed at that time demonstrated a motor abnormality of the esophagus and lower esophageal sphincter consistent with a diagnosis of achalasia. Upper endoscopy revealed a small ulcerated tumor in the cardia of the stomach. A biopsy specimen was interpreted as adenocarcinoma of the stomach. Surgical treatment included resection of the gastric tumor along with a 4-cm segment of the distal esophagus, resection of a collar of apparently uninvolved stomach, and esophagogastrostomy. Nine months following surgery the patient was restudied. An upper gastrointestinal roentgenogram demonstrated a return of esophageal caliber and configuration to normal. Manometry showed that esophageal contractions had reverted to a normal progressive, postdeglutition pattern throughout the length of the esophagus. This is the first report in which achalasia secondary to gastric adenocarcinoma was reversed after tumor resection.

Successful treatment of vigorous achalasia associated with gastric lymphoma

A 61-year-old male was evaluated for dysphagia. Esophageal manometry revealed vigorous achalasia. Upper-gastrointestinal endoscopy revealed a probable gastric neoplasm which was confirmed at laparotomy. Histologically the tumor was a lymphoma. Antineoplastic therapy resuted in rapid and complete improvement in the patient's dysphagia. Repeat esophageal manometry was normal. It is concluded that: (1) patients presenting with achalasia or vigorous achalasia should be carefully evaluated for the presence of a gastric malignancy involving the gastric fundus and lower esophagus; (2) chemotherapy may produce a resolution of esophageal symptoms.

Primary histiocytic lymphoma of the esophagus

Squamous cell carcinoma represents the most common primary malignant lesion of the esophagus (1). The initial manifestation of lymphosarcoma infrequently occurs in the gastrointestinal tract, and in one large series, there were no lymphosarcomas presenting in the esophagus (2). In the case described below, a primary histiocytic lymphoma (large cell lymphoma) was discovered in the distal esophagus.