Esophageal involvement in secondary amyloidosis mimicking achalasia

Systemic diseases affecting the GI tract: A review of clinical and histopathologic manifestations

A variety of systemic diseases may affect the gastrointestinal (GI) tract. Since the GI tract responds to injury in limited ways, identifying these processes may be challenging, especially on small endoscopic biopsies. This article reviews the clinicopathologic features of commonly encountered systemic diseases affecting the tubular GI tract: sarcoidosis, graft vs. host disease, mast cell disorders, systemic sclerosis, and IgG-4 related disease. In addition, we offer guidance in differentiating them from their mimics.

Gastrointestinal and Hepatic Disease in Rheumatoid Arthritis

Gastrointestinal (GI) manifestations of rheumatoid arthritis (RA) are rare, but can be impactful for patients. Some GI processes are directly related to RA, whereas others may be sequelae of treatment or caused by concomitant autoimmune diseases. This article discusses the role of the GI tract in RA pathogenesis; the presentation, epidemiology, and diagnosis of RA-related GI manifestations; concomitant GI autoimmune diseases that may affect those with RA; and GI side effects of RA treatment. The importance of appropriately considering conditions unrelated to RA in the differential diagnosis when evaluating new GI symptoms in patients with RA is noted.

Esophageal motor function in Familial Mediterranean Fever: a prospective evaluation of motility in 31 patients

BACKGROUND

The aims of this study were to evaluate esophageal motor function in patients with Familial Mediterranean Fever (FMF) who had upper gastrointestinal symptoms and to compare esophageal motor function between FMF patients who developed amyloidosis and patients without amyloidosis.

METHODS

31 FMF patients with dyspeptic symptoms and 31 healthy age-matched individuals were included in the study. Endoscopic examination and esophageal motility testing were performed.

RESULTS

Esophageal motor abnormalities were detected in 25.8% (8/31) of these patients [incomplete Lower esophageal sphincter (LES) relaxation: n=4, esophageal hypomotility: n=2, and hypotensive LES: n=2]. Median LES relaxation (%) (min-max) was significantly lower in patients with FMF compared to control group 94% (54-100) vs. 98% (80-100), p=0.019 respectively). However, mean LES pressure (mmHg) (19.5+/-8.9 vs. 19.7+/-5.6, p=0.813), duration of LES relaxation (s) (7.9+/-1.7 vs. 8.7+/-1.7, p=0.068), contraction amplitude of esophageal body (mmHg) (60.4+/-23.3 vs. 58.2+/-19.7, p=0.691) and median (min-max) peak velocity (s) [3.1(-1.43-50.3) vs. 3.1 (0.9-8.7), p=0.435] were similar in patients with FMF compared to control group. There were no significant differences with regard to LES pressure, LES relaxation, LES relaxation duration, contraction amplitude (mmHg) and peak velocity (sc) among patients with FMF and amyloidosis, amyloidosis negative FMF patients and healthy controls.

CONCLUSIONS

Abnormal esophageal manometric findings can be observed at least in a subgroup of patients with FMF regardless of amyloid status. Investigation of esophageal motor function in patients with FMF who exhibit unexplained upper gastrointestinal symptoms between attacks may be a helpful tool in order to delineate esophageal motor dysfunction.

Gastrointestinal manifestations of amyloidosis

Amyloidosis is characterized by extracellular deposition of abnormal protein. There are six types: primary, secondary, hemodialysis-related, hereditary, senile, and localized. Primary (AL) amyloidosis is associated with monoclonal light chains in serum and/or urine with 15% of patients having multiple myeloma. Secondary (AA) amyloidosis is associated with inflammatory, infectious, and neoplastic diseases. The presentation is protean, including macroglossia, a dilated and atonic esophagus, gastric polyps or enlarged folds, and luminal narrowing or ulceration of the colon. Amyloid deposition in the gastrointestinal (GI) tract is greatest in the small intestine. The symptoms include diarrhea, steatorrhea, or constipation. Pseudo-obstruction carries a particularly grave prognosis, often not responding to pro-motility agents. Hepatic involvement is common, but the clinical manifestations are usually mild with hepatomegaly and an elevated alkaline phosphatase level. Biopsies to diagnose amyloidosis can be taken from the fat, kidney, intestine, or bone marrow. The safety of liver biopsies is controversial. With Congo Red stain, amyloid appears red in normal light and apple-green in polarized light. Treatment for AL amyloidosis is chemotherapy and stem cell transplantation; treatment for AA amyloidosis is control of the underlying disease. Amyloidosis should be considered in patients with proteinuria, cardiomyopathy, hepatomegaly (with mildly abnormal liver tests), peripheral and autonomic neuropathy, weight loss, and GI symptoms.

Autoimmune disorders: gastrointestinal manifestations and endoscopic findings

The gastrointestinal tract can be involved in many autoimmune disorders, and women are affected more than men in most of the disease processes discussed. As this article outlines, gastrointestinal manifestations can be either part of the clinical presentation or complications of treatment. Depending on the disease process and the severity of symptoms, gastrointestinal evaluation and treatment can have an important role in the management of these diseases.

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 and secondary amyloidosis in a patient with rheumatoid arthritis]

Rheumatic diseases cover a wide spectrum of clinical syndromes and frequently present with gastrointestinal alterations. Systemic amyloidosis is associated with infectious diseases or chronic inflammatory processes such as rheumatoid arthritis and it can also affect the gastrointestinal tract. Although esophageal involvement is difficult to quantify because its course is frequently asymptomatic, systemic amyloidosis is recognized as a cause of motor disorders of the esophagus. Typical manometric patterns, including achalasia, are usually absent. Esophageal involvement due to amyloid deposits usually corresponds to primary amyloidosis as only a few cases of secondary esophageal deposits (type AA) have been described. We describe a new case of this exceptional association that first presented as dysphagia in a patient with rheumatoid arthritis. The initial suspicion of pseudoachalasia led to the definitive diagnosis of secondary amyloidosis.

Physiology and pathology of the oesophagus in the elderly patient

In the 1960s, the term 'presbyoesophagus' was introduced for what were felt to be the characteristics of the oesophagus in old age. Since then a number of sophisticated studies using modern manometric, radiological, pH-metric or endoscopic equipment have been performed to better study this subject. Although results in some aspects are still contradictory, these studies have provided us with some more detailed information on the physiology of the ageing oesophagus. Beginning with an overview of what is currently known and discussed about age-induced physiological changes in oesophageal function, this review will then focus on specific problems of oesophagus-related diseases in the elderly. The main topics discussed will include presentation, diagnosis and treatment of primary and secondary motility disorders, oesophageal manifestations of neuromuscular and neurological disease, gastro-oesophageal reflux disease and oesophageal cancer in the elderly.