Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors

Modern insights into the pathophysiology and treatment of pseudoachalasia

BACKGROUND

Secondary achalasia or pseudoachalasia is a clinical presentation undistinguishable from achalasia in terms of symptoms, manometric, and radiographic findings, but associated with different and identifiable underlying causes.

METHODS

A literature review was conducted on the PubMed database restricting results to the English language. Key terms used were "achalasia-like" with 63 results, "secondary achalasia" with 69 results, and "pseudoachalasia" with 141 results. References of the retrieved papers were also manually reviewed.

RESULTS

Etiology, diagnosis, and treatment were reviewed.

CONCLUSIONS

Pseudoachalasia is a rare disease. Most available evidence regarding this condition is based on case reports or small retrospective series. There are different causes but all culminating in outflow obstruction. Clinical presentation and image and functional tests overlap with primary achalasia or are inaccurate, thus the identification of secondary achalasia can be delayed. Inadequate diagnosis leads to futile therapies and could worsen prognosis, especially in neoplastic disease. Routine screening is not justifiable; good clinical judgment still remains the best tool. Therapy should be aimed at etiology. Even though Heller's myotomy brings the best results in non-malignant cases, good clinical judgment still remains the best tool as well.

Esophageal Dysfunction in Post-lung Transplant: An Enigma

The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.

Evaluating the impact of an enhanced triage process on the performance and diagnostic yield of oesophageal physiology studies post COVID-19

OBJECTIVES

The COVID-19 pandemic significantly impacted on the provision of oesophageal physiology investigations. During the recovery phase, triaging tools were empirically recommended by national bodies for prioritisation of referrals amidst rising waiting lists and reduced capacity. We evaluated the performance of an enhanced triage process (ETP) consisting of telephone triage combined with the hierarchical 'traffic light system' recommended in the UK for prioritising oesophageal physiology referrals.

DESIGN

In a cross-sectional study of patients referred for oesophageal physiology studies at a tertiary centre, data were compared between patients who underwent oesophageal physiology studies 6 months prior to the COVID-19 pandemic and those who were investigated within 6 months after service resumption with implementation of the ETP.

OUTCOME MEASURES

Adjusted time from referral to investigation; non-attendance rates; the detection of Chicago Classification (CC) oesophageal motility disorders on oesophageal manometry and severity of acid reflux on 24 hours pH/impedance monitoring.

RESULTS

Following service resumption, the ETP reduced non-attendance rates from 9.1% to 2.8% (p=0.021). Use of the 'traffic light system' identified a higher proportion of patients with CC oesophageal motility disorders in the 'amber' and 'red' triage categories, compared with the 'green' category (p=0.011). ETP also reduced the time to test for those who were subsequently found to have a major CC oesophageal motility diagnosis compared with those with minor CC disorders and normal motility (p=0.004). The ETP did not affect the yield or timing of acid reflux studies.

CONCLUSION

ETPs can effectively prioritise patients with oesophageal motility disorders and may therefore have a role beyond the current pandemic.

The added value of symptom analysis during a rapid drink challenge in high-resolution esophageal manometry

INTRODUCTION

Patients with esophageal symptoms often remain with an uncertain diagnosis after high-resolution manometry.

AIM

To determine the added value of concomitant pressure and symptom analysis in response to a rapid drink challenge (RDC).

METHODS

In consecutive patients referred for esophageal manometry, a RDC consisting in free drinking of 200 ml of water as quick as possible was performed after the standard single water swallows manometry. Both pressure patterns and usual symptoms induced by the RDC were analyzed.

RESULTS

A total of 1319 patients were included, (64.7% women, mean age 58.2 years, range 11-90). There were significant differences in pressure responses between patients with obstructive disorders, major hypercontractile disorders, esophageal hypomotility disorders and normal motility. The RDC provoked usual symptoms in 388 (29.4%) patients, associated with hyperpressive and obstructive patterns in 14.0% and 16.6%, respectively. Reproduction of dysphagia and regurgitation (not pain) was significantly associated with abnormal pressure responses during the RDC (p < 0.001 and p = 0.002, respectively). The RDC elicited both abnormal pressure patterns and symptoms in 6.2%, 1.6%, and 20.8% of patients with normal motility, ineffective esophageal motility, and esophago-gastric junction outflow obstruction, respectively.

CONCLUSION

Concomitant evaluation of symptoms and pressure responses to a RDC may increase the specificity of esophageal motor testing in patients with inconclusive diagnosis or normal esophageal motility.

Peroral Endoscopic Myotomy for Esophageal Motility Disorders

Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.

Esophageal motility patterns are altered in older adult patients

INTRODUCTION AND AIMS

Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age.

MATERIALS AND METHODS

A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results.

RESULTS

Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups.

CONCLUSIONS

Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.

Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.

Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry

Distal esophageal spasm (DES) is a rare major motility disorder in the Chicago classification of esophageal motility disorders (CC). DES is diagnosed by finding of ≥ 20% premature contractions, with normal lower esophageal sphincter (LES) relaxation on high-resolution manometry (HRM) in the latest version of CCv3.0. This feature differentiates it from achalasia type 3, which has an elevated LES relaxation pressure. Like other spastic esophageal disorders, DES has been linked to conditions such as gastroesophageal reflux disease, psychiatric conditions, and narcotic use. In addition to HRM, ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions. Functional lumen imaging probe (FLIP), a new cutting-edge diagnostic tool, is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP. Medical treatment in DES mostly targets symptomatic relief and often fails. Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time. Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.

Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making

Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.

Difficult peroral endoscopic myotomy: definition and management strategies

Introduction: Peroral endoscopic myotomy (POEM) has been established as an alternative endoscopic method for the treatment of achalasia, and several studies have confirmed its relatively long-term efficacy. Although most of the POEM procedures can be smoothly completed, technical difficulties do arise during the treatment of some patients, which may lead to prolonged procedure duration, increased procedure-related complications, or even aborted POEM.Area covered: In the present review, we provide a comprehensive review of difficult POEM, focusing on its definition, risk factors, and intraoperative management strategies. The present review is expected to provide tips for not so experienced operators who perform POEM.Expert commentary: Submucosal fibrosis and sigmoid-type esophagus are associated with difficult POEM. Sometimes, the following may also be associated with difficult POEM: previous endoscopic or surgical treatments, spastic esophageal disorders (type III achalasia, distal esophageal spasm, and hypercontractile esophagus), achalasia with diverticulum or situs inversus. For operators who begin to perform POEM, I suggest an exclusion of patients with severe submucosal fibrosis or sigmoid-type esophagus, and begin to perform POEM for these patients when they have completed at least 50 cases of 'easy POEM' and the proposed management strategies may be helpful.

Achalasia: It Is Not All Black and White

PURPOSE OF REVIEW

This review aims to shed light on subtleties of achalasia diagnosis, including potential pitfalls that may lead to errors. Optimal methods for assessment of disease severity and the relationship between achalasia and other motility disorders will also be reviewed with an emphasis on recent findings from the literature.

RECENT FINDINGS

Adjunctive testing with viscous substances or larger water volumes should be used routinely as it improves the accuracy of achalasia diagnosis. Chronic opiate use can mimic achalasia. The timed barium swallow remains the best test for assessments of disease severity and prognostication, but the functional lumen-imaging probe, a newer tool which measures esophagogastric junction distensibility using impedance planimetry, is emerging as a potentially more powerful tool for these purposes. Functional esophagogastric junction outflow obstruction is possibly part of the achalasia spectrum. By addressing the potential pitfalls described, and through routine and standardized use of the diagnostic tools mentioned herein, the accuracy of diagnosis, severity assessment, and prognostication of achalasia can be improved.

Do Jackhammer contractions lead to achalasia? A longitudinal study

BACKGROUND

Jackhammer esophagus (JE) is a rare esophageal motility disorder defined in the Chicago Classification of Esophageal Motility by presence of excessively high distal contractile integral (DCI) on high-resolution manometry (HRM), with unknown natural manometric course. We examined the development of achalasia over time in patients with JE.

METHODS

Through a retrospective longitudinal design, patients with Jackhammer contractions who had more than one HRM between 2005 and 2015 were identified. Any change in manometric finding was assessed for the presence of achalasia. Demographic and manometric risk factors for this progression were then sought in univariate analysis.

KEY RESULTS

Of 3363 HRM studies, 229 subjects had multiple manometries, accounting for 528 studies. Twelve subjects met our inclusion criteria for JE on any of the multiple tests, represented by 27 studies for a total of 347 patient-months of manometric follow-up. Subjects with JE whose manometry included impedance demonstrated consistent esophageal bolus clearance. Of 12 subjects with Jackhammer contractions, three subjects progressed to type III achalasia, over a mean of 24 months (range: 19-31 months). At the time of diagnosis with JE, impaired esophago-gastric junction relaxation was seen in all three subjects and was the only risk factor that could predict progression to achalasia (P<.01).

CONCLUSIONS & INFERENCES

In this unique study of the natural course of JE, we have shown that JE can progress to achalasia. Manometric findings at the time of JE diagnosis might predict this progression.

Ineffective Esophageal Motility Progressing into Distal Esophageal Spasm and Then Type III Achalasia

The clinical significance of minor esophageal motility disorders is unclear, though they typically carry a benign course. Distal esophageal spasm progressing to achalasia has been reported, although it appears to be rare. We report a case of a patient with dysphagia and chest pain who was found to have ineffective esophageal motility on high-resolution manometry, which developed into distal esophageal spasm and then progressed to type III achalasia.

Lymphocytic Esophagitis in Nonachalasia Primary Esophageal Motility Disorders: Improved Criteria, Prevalence, Strength of Association, and Natural History

Lymphocytic esophagitis (LE) is a histologic pattern with no established clinical correlates in the majority of patients. The goal of this study was to evaluate the association between nonachalasia primary esophageal motility disorders (PEMD) and LE. Sixty-nine patients with PEMD and esophageal biopsies, including 22 with nutcracker esophagus, 33 with ineffective motility, and 14 with diffuse spasm, constituted the study group. The control group consisted of 70 patients with severe dysmotility-negative gastroesophageal reflux disease requiring referral for Nissen fundoplication. To improve the criteria for LE, a lymphocyte reference range at different esophageal levels was first established in 17 healthy volunteers. The cutoffs for normal intraepithelial lymphocytes, defined as lymphocyte levels not exceeding mean level±2 SDs, were set at 62, 46, and 41 lymphocytes per high-power field at 0 to 2, 5, and 10 cm above the gastroesophageal junction, respectively. Predominantly focal peripapillary LE was observed in approximately 40% of patients with nutcracker esophagus or diffuse spasm and in 20% of patients with ineffective motility, in comparison with 4% of patients with dysmotility-negative gastroesophageal reflux disease (P<0.035 vs. any subtype of PEMD). Overall, LE was strongly associated with PEMD in multivariate analysis (adjusted odds ratio, 7.93; 95% confidence interval, 2.26-27.9; P=0.001). LE had a chronic course in 56% of the patients with follow-up biopsies. In conclusion, LE has a strong association with PEMD, suggesting the utility of LE in raising the possibility of PEMD.

Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms

The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.

Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations

BACKGROUND AND AIMS

Eight years have passed since the introduction of the per-oral endoscopy myotomy (POEM) procedure. POEM was initially received as an investigational procedure, but since the revelation of promising safety and efficacy data, it is becoming the preferred treatment for achalasia. With the recent completion of our 1000th POEM procedure, we share our experience and knowledge through the discussion of clinical pearls, pitfalls, and practical considerations.

METHODS

The various aspects of the procedure and conditions that warrant special attention are discussed from our perspective, with a focus on areas in which there is currently limited evidence.

RESULTS

The key points on patient position, submucosal tunneling, myotomy, closure, intraprocedural bleeding, and advanced sigmoid achalasia are presented.

CONCLUSIONS

The dissemination of this information serves as a foundation for new POEM operators and as a catalyst for more-experienced operators to further refine and advance their POEM skills and stimulate international discourse and collaboration.

Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter

BACKGROUND AND STUDY AIMS

With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed.

PATIENTS AND METHODS

Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM.

RESULTS

All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution.

CONCLUSIONS

POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.

POEM, the Prototypical "New NOTES" Procedure and First Successful NOTES Procedure

Peroral endoscopic myotomy (POEM) was first performed in 2008 as a novel treatment of achalasia. It is now performed globally, demonstrating the evolution of the first successful natural orifice transluminal endoscopic surgery (NOTES) procedure. There is extensive data demonstrating the safety and efficacy of POEM, and now long-term data has emerged demonstrating that the efficacy is durable. POEM is also being used to successfully treat diffuse esophageal spasm (DES) and jackhammer esophagus. With jackhammer esophagus and DES, inclusion of the lower esophageal sphincter in the myotomy minimizes the risk of symptom development from iatrogenic ineffective esophageal motility.

Distal esophageal spasm and the Chicago classification: is timing everything?

BACKGROUND

According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as premature esophageal contractions (distal latency [DL] <4.5 s) for ≥20% of swallows, in the presence of a normal mean integral relaxation pressure (IRP). However, some patients with symptoms of DES have rapid contractions with a normal DL. The aim of this study was to characterize these patients and compare their clinical characteristics to those of patients classified as DES.

METHODS

We retrospectively compared clinical characteristics and high-resolution manometry findings of patients with rapid contractions with normal latency to those meeting the Chicago classification criteria for DES.

KEY RESULTS

Over a 3-year period, nine patients were diagnosed with DES and 14 showed rapid contractions in the distal esophagus with normal latency. The latter were younger than DES patients (60 ± 4 vs 72 ± 3 years, p < 0.05). Dysphagia and retrosternal pain occurred to a similar degree in both groups. Weight loss and abnormal barium esophagogram tended to be more frequent in DES patients. There was no difference in contractile front velocity (CFV) and in distal contractile integral (DCI) between patients with DES and rapid contractions with normal latency. Lower esophageal sphincter pressures were not different between groups. However, IRP was significantly higher in DES compared to rapid contractions with normal latency (11.7 ± 0.6 mmHg vs 7.6 ± 1.2 mmHg, p < 0.05), albeit still within the normal range.

CONCLUSIONS & INFERENCES

These data suggest that patients with simultaneous contractions with normal latency represent a group of patients with many features similar to DES.

Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is a newly described diagnostic entity growing in importance due to the use of high resolution manometry (HRM). There is little knowledge regarding its incidence, etiopathogeny, long-term evolution, and most suitable treatment. Our objective was to increase the awareness of EGJOO to optimize the management of these patients.

METHODS

We conducted a historical (retrospective and prospective) study of patients diagnosed with EGJOO using HRM combined with multichannel intraluminal impedance, comparing their manometric and impedance characteristics with those of a control group. Symptoms, etiology of obstruction, acid exposure, clinical course (and its associated factors), and response to treatment were also evaluated in the EGJOO group.

KEY RESULTS

Forty-four subjects were included (28 patients and 16 controls). Esophagogastric junction outflow obstruction patients presented incomplete esophageal transit more frequently than controls. Patients with structural obstruction had dysphagia more frequently than patients with functional obstruction, and different manometric, impedance, and pH-metric patterns. Over one-third of the EGJOO patients presented a spontaneous resolution of symptoms without EGJOO treatment. In the multivariate analysis, the variables associated with this spontaneous symptomatic resolution included typical symptoms of gastro-esophageal reflux disease or epigastralgia as the main symptom and resting or basal pressure of the upper esophageal sphincter <50 mmHg.

CONCLUSIONS & INFERENCES

The majority of EGJOO patients presented intact peristalsis which may compensate for the lack of EGJ relaxation. In the EGJOO patients presenting favorable factors associated with a spontaneous resolution of symptoms, invasive treatments should be considered with special caution. Structural etiologies are more amenable to management, while the remainder may improve without intervention.

Progression of Jackhammer Esophagus to Type II Achalasia

It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia.

Distal esophageal spasm

PURPOSE OF REVIEW

Distal esophageal spasm (DES) is a rare esophageal motility disorder associated with dysphagia and chest pain. In 2011, the diagnosis of DES was refined based on the occurrence of premature (rather than rapid) contractions by high-resolution manometry. New therapeutic options have also been recently proposed. Thus, a review on DES incorporating publications since 2012 is timely because of these revisions in definition and management.

RECENT FINDINGS

DES remains a heterogeneous clinical disorder. Its pathophysiology is still debated and DES might be related to achalasia. Alternatively, it might be secondary to medications, especially opiates. Endoscopic ultrasound might be informative diagnostically by demonstrating muscularis propria hypertrophy and thickening. Botulinum toxin injection in the esophageal body has been shown superior to placebo to relieve symptoms associated with DES. Finally, per oral endoscopic myotomy is a promising therapeutic approach, but may be less effective in DES than in achalasia.

SUMMARY

The diagnosis of DES should lead to a systematic search for medication that might promote the occurrence of esophageal dysmotility. Endoscopic treatment of DES (botulinum toxin injection or per oral endoscopic myotomy) should be further evaluated in controlled studies using current diagnostic criteria by high-resolution manometry.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

Review of current diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter

PURPOSE OF REVIEW

To cover the diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter. An outline of the presentation and manometric features of these conditions will precede a discussion of therapies. All of these diagnoses are made manometrically, even though they may be suspected by presentation and by findings at video fluoroscopic swallow or gastroscopy testing.

RECENT FINDINGS

The advent of high-resolution manometry testing has allowed a better understanding of these motility disorders, and the ability to standardize the diagnoses by the use of the Chicago Classification is a major step forward. Recent developments show that botulinum toxin and perioral myotomy can be an effective treatment for some patients. This should bring more therapies to the fore in the future, but at present there is still the need for more prospective study of best therapies.

SUMMARY

The important point to remember for all of these conditions is that unlike achalasia, there is no definite pathological correlation to the manometrically observed abnormalities. This therefore makes the management challenging and means that treatment pathways are not as well set out as for some other upper gastrointestinal motility problems.

The spectrum of achalasia: lessons from studies of pathophysiology and high-resolution manometry

High-resolution manometry and recently described analysis algorithms, summarized in the Chicago Classification, have increased the recognition of achalasia. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or with peristalsis. Any of these phenotypes could indicate achalasia; however, without a disease-specific biomarker, no manometric pattern is absolutely specific. Laboratory studies indicate that achalasia is an autoimmune disease in which esophageal myenteric neurons are attacked in a cell-mediated and antibody-mediated immune response against an uncertain antigen. This autoimmune response could be related to infection of genetically predisposed subjects with herpes simplex virus 1, although there is substantial heterogeneity among patients. At one end of the spectrum is complete aganglionosis in patients with end-stage or fulminant disease. At the opposite extreme is type III (spastic) achalasia, which has no demonstrated neuronal loss but only impaired inhibitory postganglionic neuron function; it is often associated with accentuated contractility and could be mediated by cytokine-induced alterations in gene expression. Distinct from these extremes is progressive plexopathy, which likely arises from achalasia with preserved peristalsis and then develops into type II achalasia and then type I achalasia. Variations in its extent and rate of progression are likely related to the intensity of the cytotoxic T-cell assault on the myenteric plexus. Moving forward, we need to integrate the knowledge we have gained into treatment paradigms that are specific for individual phenotypes of achalasia and away from the one-size-fits-all approach.

Distal esophageal spasm: an update

Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.

Management of spastic disorders of the esophagus

The concept of esophageal spastic disorders encompasses spastic achalasia, distal esophageal spasm, and jackhammer esophagus. These are conceptually distinct in that spastic achalasia and distal esophageal spasm are characterized by a loss of neural inhibition, whereas jackhammer esophagus is associated with hypercontractility. Hypercontractility may also occur as a result of esophagogastric junction outflow obstruction or inflammation. The diagnosis of jackhammer esophagus as a primary motility disorder is based on the characteristic manometric findings after ruling out mechanical obstruction and eosinophilic esophagitis. Despite the differences in pathophysiology among the esophageal spastic disorders, their management is similar.

Imaging evaluation of dogs and cats with Dysphagia

The current literature is reviewed in this paper regarding the application of diagnostic imaging in the evaluation of swallowing disorders of the dog. The applications of radiography, contrast radiography, and contrast videofluoroscopy are discussed with pertinent case examples provided for emphasis. The indications for image-guided interventions are also described.