1
|
Goyal RK, Rattan S. Role of mechanoregulation in mast cell-mediated immune inflammation of the smooth muscle in the pathophysiology of esophageal motility disorders. Am J Physiol Gastrointest Liver Physiol 2024; 326:G398-G410. [PMID: 38290993 DOI: 10.1152/ajpgi.00258.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 02/01/2024]
Abstract
Major esophageal disorders involve obstructive transport of bolus to the stomach, causing symptoms of dysphagia and impaired clearing of the refluxed gastric contents. These may occur due to mechanical constriction of the esophageal lumen or loss of relaxation associated with deglutitive inhibition, as in achalasia-like disorders. Recently, immune inflammation has been identified as an important cause of esophageal strictures and the loss of inhibitory neurotransmission. These disorders are also associated with smooth muscle hypertrophy and hypercontractility, whose cause is unknown. This review investigated immune inflammation in the causation of smooth muscle changes in obstructive esophageal bolus transport. Findings suggest that smooth muscle hypertrophy occurs above the obstruction and is due to mechanical stress on the smooth muscles. The mechanostressed smooth muscles release cytokines and other molecules that may recruit and microlocalize mast cells to smooth muscle bundles, so that their products may have a close bidirectional effect on each other. Acting in a paracrine fashion, the inflammatory cytokines induce genetic and epigenetic changes in the smooth muscles, leading to smooth muscle hypercontractility, hypertrophy, and impaired relaxation. These changes may worsen difficulty in the esophageal transport. Immune processes differ in the first phase of obstructive bolus transport, and the second phase of muscle hypertrophy and hypercontractility. Moreover, changes in the type of mechanical stress may change immune response and effect on smooth muscles. Understanding immune signaling in causes of obstructive bolus transport, type of mechanical stress, and associated smooth muscle changes may help pathophysiology-based prevention and targeted treatment of esophageal motility disorders.NEW & NOTEWORTHY Esophageal disorders such as esophageal stricture or achalasia, and diffuse esophageal spasm are associated with smooth muscle hypertrophy and hypercontractility, above the obstruction, yet the cause of such changes is unknown. This review suggests that smooth muscle obstructive disorders may cause mechanical stress on smooth muscle, which then secretes chemicals that recruit, microlocalize, and activate mast cells to initiate immune inflammation, producing functional and structural changes in smooth muscles. Understanding the immune signaling in these changes may help pathophysiology-based prevention and targeted treatment of esophageal motility disorders.
Collapse
Affiliation(s)
- Raj K Goyal
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, United States
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, United States
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Sidney Kummel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| |
Collapse
|
2
|
Vahedi F, Low EE, Kaizer AM, Fehmi SA, Hasan A, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Yadlapati R. Esophageal anatomy and physiology vary across spastic and non-spastic phenotypes of disorders of esophagogastric junction outflow. Neurogastroenterol Motil 2024; 36:e14709. [PMID: 38009826 PMCID: PMC10843578 DOI: 10.1111/nmo.14709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pathophysiologic mechanisms of disorders of esophagogastric junction (EGJ) outflow are poorly understood. We aimed to compare anatomic and physiologic characteristics among patients with disorders of EGJ outflow and normal motility. METHODS We retrospectively evaluated adult patients with achalasia types 1, 2, 3, EGJ outflow obstruction (EGJOO) or normal motility on high-resolution manometry who underwent endoscopic ultrasound (EUS) from January 2019 to August 2022. Thickened circular muscle was defined as ≥1.6 mm. Characteristics from barium esophagram (BE) and functional lumen imaging probe (FLIP) were additionally assessed. KEY RESULTS Of 71 patients (mean age 56.2 years; 49% male), there were 8 (11%) normal motility, 58 (82%) had achalasia (5 (7%) type 1, 32 (45%) classic type 2, 21 (30%) type 3 [including 12 type 2 with FEPs]), and 7 (7%) had EGJOO. A significantly greater proportion of type 3 achalasia had thickened distal circular muscle (76.2%) versus normal motility (0%; p < 0.001) or type 2 achalasia (25%; p < 0.001). Type 1 achalasia had significantly wider mean maximum esophageal diameter on BE (57.8 mm) compared to type 2 achalasia (32.8 mm), type 3 achalasia (23.4 mm), EGJOO (15.9 mm), and normal motility (13.5 mm). 100% type 3 achalasia versus 0% type 1 achalasia/normal motility had tertiary contractions on BE. Mean EGJ distensibility index on FLIP was lower for type 3 achalasia (1.2 mmHg/mm2 ) and EGJOO (1.2 mmHg/mm2 ) versus type 2 (2.3 mmHg/mm2 ) and type 1 achalasia (2.9 mmHg/mm2 ). CONCLUSIONS Our findings suggest distinct pathologic pathways may exist: type 3 achalasia and EGJOO may represent a spastic outflow phenotype consisting of a thickened, spastic circular muscle, which is distinct from type 1 and 2 achalasia consisting of a thin caliber circular muscle layer with more prominent esophageal dilation.
Collapse
Affiliation(s)
- Farnoosh Vahedi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Eric E Low
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Michael A Chang
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Mary L Krinsky
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| |
Collapse
|
3
|
Nakai T, Abe H, Tanaka S, Kawara F, Toyonaga T, Sakaguchi H, Ueda C, Ikezawa N, Tsuda K, Urakami S, Kodama Y. Risk-scoring system for predicting challenging cases of peroral endoscopic myotomy. Dig Endosc 2023; 35:729-735. [PMID: 36571213 DOI: 10.1111/den.14508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Peroral endoscopic myotomy (POEM) is an effective treatment for esophageal motility disorders including achalasia and its variants. However, some surgeons have encountered challenging cases. This study aimed to develop a risk-scoring system to predict challenging cases of POEM. METHODS Consecutive patients who underwent POEM between April 2015 and March 2020 at our hospital were included in this single-center retrospective study. Challenging cases of POEM were defined as patients with any of the following: (i) procedure time ≥90 min; (ii) mucosal perforation; (iii) pneumothorax; and (iv) major bleeding. A risk-scoring system for predicting challenging cases was developed based on multivariate logistic regression and internal validation was performed using the bootstrap method. Clinical usefulness was evaluated using a decision curve analysis. RESULTS Of the 467 patients, 59 (12.6%) had challenging POEM. A risk-scoring system consisted of four variables: duration of symptoms ≥5 years (assigned score, 1 point), antithrombotics use (1 point), manometric diagnosis of achalasia variants (2 points), and dilation grade 3 (2 points). Our scoring system showed satisfactory discrimination (area under the receiver operating characteristic curve, 0.69; 95% confidence interval [CI] 0.61-0.77) and calibration (slope, 0.99; 95% CI 0.65-1.35). The decision curve analysis demonstrated its clinical usefulness. CONCLUSIONS We established a risk-scoring system to predict challenging cases of POEM. This scoring system may aid the selection of patients who require treatment from experienced surgeons.
Collapse
Affiliation(s)
- Tatsuya Nakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Fumiaki Kawara
- Division of Gastroenterology, Konan Medical Center, Hyogo, Japan
| | | | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Chise Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Nobuaki Ikezawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kazunori Tsuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Satoshi Urakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| |
Collapse
|
4
|
Kim AJS, Ong S, Kim JH, Lee HS, Yoon JS, Hur DY. Morphologic Changes in Esophageal Body Movement During Bolus Transport After Peroral Endoscopic Myotomy in Type III Achalasia. J Neurogastroenterol Motil 2022; 28:131-144. [PMID: 34980696 PMCID: PMC8748845 DOI: 10.5056/jnm21020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 03/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background/Aims The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia. Methods Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed. Results The MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group. Conclusions POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.
Collapse
Affiliation(s)
- Alex Ju Sung Kim
- Department of Anatomy and Tumor Immunology, Inje University College of Medicine, Busan, Korea
| | - Sungmoon Ong
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea.,Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dae Young Hur
- Department of Anatomy and Tumor Immunology, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
5
|
Milito P, Siboni S, Bonavina L. High-Pressure Tactics: Jackhammer Esophagus-Diagnosing Is Easier than Treating. Dig Dis Sci 2022; 67:1200-1203. [PMID: 34674073 PMCID: PMC8529866 DOI: 10.1007/s10620-021-07279-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 12/09/2022]
Abstract
Diagnosis of esophageal disorders is well ahead of available treatment options. With HRM, for example, one can identify numerous conditions and their variants, which may lose meaning if the clinical and therapeutic implications of these subclassifications are limited. We report an exemplary case of a patient with hiatal hernia complaining of reflux, dysphagia, and chest pain refractory to medical treatment. Jackhammer esophagus was diagnosed and a hybrid approach consisting of POEM and concomitant crural repair and Dor fundoplication is proposed.
Collapse
Affiliation(s)
- Pamela Milito
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy ,Department of General and Foregut Surgery, I.R.C.C.S. Policlinico San Donato, University of Milan, Piazza Malan 1, San Donato Milanese, 20097 Milan, Italy
| |
Collapse
|
6
|
Liao Y, Xiao TY, Wu YF, Zhang JJ, Zhang BZ, Wang YD, Wang S, Liu X, Sun SY, Guo JT. Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia. World J Gastroenterol 2020; 26:5863-5873. [PMID: 33132640 PMCID: PMC7579762 DOI: 10.3748/wjg.v26.i38.5863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/13/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.
AIM To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.
METHODS All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.
RESULTS Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening (P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course (P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.
CONCLUSION Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.
Collapse
Affiliation(s)
- Ye Liao
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Ting-Yue Xiao
- Department of Science and Education, Shenyang Sixth People’s Hospital, Shenyang 110006, Liaoning Province, China
| | - Yu-Fan Wu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Jing-Jing Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Bao-Zhen Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yi-Dan Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Sheng Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiang Liu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Si-Yu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Jin-Tao Guo
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| |
Collapse
|
7
|
Endoscopic ultrasound: a powerful tool to modify treatment algorithms in opioid-induced achalasia. Surg Endosc 2020; 35:4585-4594. [PMID: 32845401 DOI: 10.1007/s00464-020-07882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia. METHODS From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness > 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test. RESULTS 45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24-93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/m2, mean BMI in the primary achalasia group 26.8 kg/m2 (p = 0.11). In comparing endoscopic maximum round layer thickness between groups, non-opioid patients had a thicker round muscle layer (2.7 mm vs 1.8 mm, p = 0.05). Length of abnormally thickened esophageal muscle (greater than 1.8 mm) also differed between the two groups; patients on opioids had a shorter length of thickening (4.0 cm vs 0.0 cm, p = 0.04). Intervention rate was higher in the non-opioid group (p = 0.79). Of the patients that underwent therapeutic intervention, symptom resolution was higher in the non-opioid group (p = 0.002), while re-intervention post-procedure for persistent symptomatology was elevated in the opioid subset (p = 0.06). Patients in the opioid group were less likely to undergo invasive treatment (Heller). As of 2017 all interventions in the opioid group have been endoscopic. CONCLUSION Endoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users.
Collapse
|
8
|
Evaluation and Management of Premalignant Conditions of the Esophagus: A Systematic Survey of International Guidelines. J Clin Gastroenterol 2019; 53:627-634. [PMID: 31403982 DOI: 10.1097/mcg.0000000000001247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal cancer represents one of the most lethal forms of malignancy. The growing incidence of esophageal adenocarcinoma represents an emerging public health concern. This review article summarizes current diagnostic, management, and therapeutic practices of premalignant conditions of the esophagus including Barrett's esophagus, tylosis, granular cell tumors, achalasia, and the ingestion of caustic substances. Our report provides clinicians and academics with a global clinical perspective regarding presentation, surveillance guidelines, and therapeutic management of these esophageal conditions.
Collapse
|
9
|
Lee JH, Lee YJ, Lee JM, Ju MJ, Yang MA, Choi MW, Yun SH. Early Phase of Achalasia Manifested as an Esophageal Subepithelial Tumor. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:110-114. [PMID: 31438662 DOI: 10.4166/kjg.2019.74.2.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/03/2022]
Abstract
The Chicago classification (CC) defines an esophagogastric junction outflow obstruction (EGJOO) as the presence of several instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and a discrepancy from the criteria of achalasia. The revised CC addresses the potential etiology of EGJOO, including the early forms of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia. A 58-year-old woman visited the Presbyterian Medical Center with swallowing difficulty. The patient underwent a high resolution manometry (HRM) examination and was diagnosed with EGJOO. Chest CT was performed to exclude a mechanical obstruction as a cause, and CT revealed a subepithelial tumor (SET) at the upper part of the esophagogastric junction. Therefore, laparoscopic surgery was performed and eccentric muscular hypertrophy of the distal esophagus was observed. Longitudinal myotomy and Dor fundoplication were also performed. The histology findings of the surgical specimens were consistent with achalasia. This paper reports a case of early achalasia that was finally diagnosed by the histology findings, but was initially diagnosed as EGJOO using HRM and misdiagnosed as SET in the image study.
Collapse
Affiliation(s)
- Jong Hwa Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Young Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jong Myeong Lee
- Division of Gastroenterology, Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Myoung Jin Ju
- Division of Gastroenterology, Department of Pathology, Presbyterian Medical Center, Jeonju, Korea
| | - Min A Yang
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Myung Woo Choi
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - So Hee Yun
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| |
Collapse
|
10
|
Watanabe D, Tanaka S, Kawara F, Abe H, Ariyoshi R, Nakano Y, Takao T, Morita Y, Toyonaga T, Umegaki E, Kodama Y. Clinical impact of peroral endoscopic myotomy for esophageal motility disorders on esophageal muscle layer thickness. Endosc Int Open 2019; 7:E525-E532. [PMID: 31041369 PMCID: PMC6447396 DOI: 10.1055/a-0838-5268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/13/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Previously, we reported that esophageal muscle layer thickness was associated with technical complexity of peroral endoscopic myotomy (POEM). However, there are no data regarding the mid-term effects of POEM procedures on esophageal muscle layer thickness. Therefore, we conducted this study to elucidate mid-term effects of POEM procedures, and to examine whether postoperative changes in esophageal muscle layer thickness were related to particular clinico-pathological features in patients with esophageal motility disorders. Patients and methods Seventy-four consecutive patients with esophageal motility disorders who underwent POEM at Kobe University Hospital from April 2015 to December 2016 were prospectively recruited into this study. First, we investigated the esophageal muscle layer thickness values obtained at 1 year after POEM. Second, we evaluated the effects of a reduction in muscle layer thickness on various clinico-pathological features. Results At 1 year after POEM, mean thickness of the inner circular muscle at 0 cm, 5 cm, and 10 cm from the esophagogastric junction was 1.06 ± 0.45 mm, 0.99 ± 0.36 mm, and 0.97 ± 0.44 mm, respectively. Among all sites, muscle layer thickness had significantly decreased after POEM. However, univariate logistic regression analysis demonstrated that no clinical factors were associated with esophageal muscle layer thickness after POEM procedure. Conclusions We demonstrated for the first time that thickness of the esophageal muscle layer was significantly decreased after POEM. This result reveals that changes in esophageal muscle layer thickness caused by esophageal motility disorders are reversible.
Collapse
Affiliation(s)
- Daisuke Watanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan,Corresponding author Shinwa Tanaka Department of Endoscopy, Kobe University Hospital7-5-1 Chuo-ku, Kusunoki-cho, Kobe, Hyogo650-0017Japan+81-78-382-6309
| | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Hirohumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Ryusuke Ariyoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Yoshiko Nakano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Toshitatsu Takao
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Takashi Toyonaga
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| |
Collapse
|
11
|
The role of endoscopic ultrasound for the evaluation and treatment of esophageal motility disorders. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
12
|
Watanabe D, Tanaka S, Ariyoshi R, Abe H, Kawara F, Toyonaga T. Muscle layer thickness affects the peroral endoscopic myotomy procedure complexity. Dis Esophagus 2018; 31:4956133. [PMID: 29617752 DOI: 10.1093/dote/doy009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders can cause severe dysphagia, regurgitation, and/or noncardiac chest pain due to a lack of coordinated esophageal motility function. However, the clinical significance of esophageal muscle layer thickness remains unclear. The aims of this study are to elucidate the clinical significance of esophageal muscle layer thickness in patients with esophageal motility disorders who undergo peroral endoscopic myotomy (POEM), and to identify predictors of a longer POEM procedure time. Seventy-four consecutive patients with esophageal motility disorders who underwent POEM procedures at Kobe University Hospital from April 2015 to December 2016 were prospectively recruited into this study. First, we investigated the associations between the thickness of the esophageal muscular layer and clinical parameters. There were no significant differences, except in the POEM procedure time, between the patients with esophageal muscle layer thickness values of ≥1.5 mm (group A) and <1.5 mm (group B). However, the relative frequency of a longer POEM procedure time (≥78 min) was significantly higher in group A than in group B (66.7% vs. 19.5, P < 0.0001). Next, independent clinical factors that were related to longer POEM procedures were investigated. Multivariate logistic regression analysis with stepwise selection demonstrated that a thick esophageal muscle layer and the length of myotomy were an independent predictor of a longer POEM procedure (odds ratio: 13.9 and 12.0, respectively). Our results indicate that preoperative endoscopic ultrasonography evaluations can help to predict the technical complexity of POEM procedures.
Collapse
Affiliation(s)
- D Watanabe
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| | - S Tanaka
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| | - R Ariyoshi
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| | - H Abe
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| | - F Kawara
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| | - T Toyonaga
- Department of Endoscopy, Kobe University Hospital, Chuo-ku, Kobe, Japan
| |
Collapse
|
13
|
Li SW, Tseng PH, Chen CC, Liao WC, Liu KL, Lee JM, Lee YC, Chuah SK, Wu MS, Wang HP. Muscular thickness of lower esophageal sphincter and therapeutic outcomes in achalasia: A prospective study using high-frequency endoscopic ultrasound. J Gastroenterol Hepatol 2018; 33:240-248. [PMID: 28475827 DOI: 10.1111/jgh.13816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/01/2017] [Accepted: 05/03/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Patients with achalasia typically have thicker lower esophageal sphincter muscles, which can affect the distensibility of the esophagogastric junction. We aimed to assess whether these muscular features, measured using high-frequency endoscopic ultrasound, affect treatment outcomes. METHODS Consecutive adult patients with suspected achalasia were enrolled prospectively. They underwent a comprehensive diagnostic workup, including endoscopic ultrasound. The thickness of the lower esophageal sphincter, including the internal circular and outer longitudinal muscles, was measured using a 12-MHz ultrasonic miniprobe. Follow-up was performed at 1 month and then at 6-month intervals, after treatment. Treatment response was defined as a reduction in Eckardt score to ≤3 or an improvement in the height of the timed barium esophagogram of ≥50%. RESULTS Of the 29 patients who received pneumatic dilatation, all but one (96.6%) exhibited a good short-term treatment response. At an average follow-up time of 18.5 (12-55.5) months, patients who had a mid-term recurrence after pneumatic dilatation had a significantly thicker outer longitudinal muscle (1.8 [1.5-1.8] vs 0.9 [0.8-1.7] mm, P = 0.036), but not internal circular muscle (2.0 [1.9-2.5] vs 2.1 [1.2-2.7] mm, P = 0.874) or total lower esophageal sphincter (3.7 [3.5-4.4] vs 3.6 [2.0-4.1] mm, P = 0.362). Patients with an outer longitudinal muscle ≥1.3 mm thick had a significantly lower mid-term remission rate than others (36.3% vs 100%, P = 0.01). CONCLUSION Thickening of the outer longitudinal muscle at the lower esophageal sphincter is associated with poor mid-term treatment outcomes for achalasia patients treated with pneumatic dilatation.
Collapse
Affiliation(s)
- Shih-Wei Li
- Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Radiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jang-Ming Lee
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
14
|
Ang D, Misselwitz B, Hollenstein M, Knowles K, Wright J, Tucker E, Sweis R, Fox M. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. Lancet Gastroenterol Hepatol 2017; 2:654-661. [PMID: 28684262 DOI: 10.1016/s2468-1253(17)30148-6] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/01/2017] [Accepted: 05/05/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The use of high-resolution manometry (HRM) to diagnose oesophageal motility disorders is based on ten single water swallows (SWS); however, this approach might not be representative of oesophageal function during the ingestion of normal food. We tested whether inclusion of a standardised solid test meal (STM) to HRM studies increases test sensitivity for major motility disorders. Additionally, we assessed the frequency and cause of patient symptoms during STM. METHODS Consecutive patients who were referred for investigation of oesophageal symptoms were recruited at Nottingham University Hospitals (Nottingham, UK) in the development study and at University Hospital Zürich (Zürich, Switzerland) in the validation study. HRM was done in the upright, seated position with a solid-state assembly. During HRM, patients ingested ten SWS, followed by a standardised 200 g STM. Diagnosis of oesophageal motility disorders was based on the Chicago Classification validated for SWS (CCv3) and with STM (CC-S), respectively. These studies are registered with ClinicalTrials.gov, numbers NCT02407938 and NCT02397616. FINDINGS The development cohort included 750 patients of whom 360 (48%) had dysphagia and 390 (52%) had reflux or other symptoms. The validation cohort consisted of 221 patients, including 98 (44%) with dysphagia and 123 (56%) with reflux symptoms. More patients were diagnosed with a major motility disorder by use of an STM than with SWS in the development set (321 [43%] patients diagnosed via STM vs 163 [22%] via SWS; p<0·0001) and validation set (73 [33%] vs 49 [22%]; p=0·014). The increase was most evident in patients with dysphagia (241 [67%] of 360 patients on STM vs 125 [35%] patients on SWS in the development set, p<0·0001), but was also present in those referred with reflux symptoms (64 [19%] of 329 patients vs 32 [10%] patients in the development set, p=0·00060). Reproduction of symptoms was reported by nine (1%) of 750 patients during SWS and 461 (61%) during STM (p<0·0001). 265 (83%) of 321 patients with major motility disorders and 107 (70%) of 152 patients with minor motility disorders reported symptoms during the STM (p=0·0038), compared with 89 (32%) of 277 patients with normal motility as defined with CC-S (p<0·0001). INTERPRETATION The diagnostic sensitivity of HRM for major motility disorders is increased with use of the STM compared with SWS, especially in patients with dysphagia. Observations made during STM can establish motility disorders as the cause of oesophageal symptoms. FUNDING None.
Collapse
Affiliation(s)
- Daphne Ang
- Clinic of Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland; Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Benjamin Misselwitz
- Clinic of Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Michael Hollenstein
- Clinic of Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Kevin Knowles
- Oesophageal Laboratory, Department of Academic Surgery, Nottingham University Hospitals, Nottingham, UK
| | - Jeff Wright
- Oesophageal Laboratory, Department of Academic Surgery, Nottingham University Hospitals, Nottingham, UK
| | - Emily Tucker
- Oesophageal Laboratory, Department of Academic Surgery, Nottingham University Hospitals, Nottingham, UK; NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Rami Sweis
- Oesophageal Laboratory, University College London, London, UK
| | - Mark Fox
- Clinic of Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland; NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK; Abdominal Center: Gastroenterology, St Claraspital, Basel, Switzerland.
| |
Collapse
|
15
|
Abstract
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.
Collapse
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK.
- St. Vincent's Hospital Sydney, Department Gastroenterology, 235 Euston Rd, 390 Victoria St, NSW, 2010, Australia.
| | - Rami Sweis
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK
| |
Collapse
|
16
|
Santander C, Perea E, Caldas M, Clave P. Catheter-based high-frequency intraluminal ultrasound imaging is a powerful tool to study esophageal dysmotility patients. Ann N Y Acad Sci 2017; 1395:60-66. [PMID: 28141904 DOI: 10.1111/nyas.13313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
High-resolution manometry (HRM) is currently the most important diagnostic test for esophageal motility disorders, providing information on the contraction pattern of the circular muscle layer, which helps classify these esophageal motor diseases. However, with the increasing development of ultrasound, other techniques, such as high-frequency intraluminal ultrasound (HFIUS), have gained importance. This technique uses a flexible shaft with a central wire integrated into a standard endoscope, which facilitates real-time sonography. Its main utility is to provide anatomical information on the structure of the esophageal wall, including both the circular and longitudinal layers that constitute the esophageal muscularis propria. Increasing knowledge about these motility disorders has led to the hypothesis that, in addition to an abnormal contraction pattern of the circular muscle, an overall increased muscle thickness and an abnormal longitudinal muscle contraction could be added as pathophysiological factors. The increase in muscle thickness could be an important indicator of the severity of diseases, such as achalasia, distal esophageal spasm, or hypercontractile esophagus. More studies are required before definitive conclusions can be reached, but HFIUS employed simultaneously with HRM could provide a more complete and precise evaluation of these esophageal motor disorders.
Collapse
Affiliation(s)
- Cecilio Santander
- Division of Gastroenterology and Hepatology, Digestive Motility Unit, IIS-IP and CIBEREHD, Universidad Autónoma de Madrid, Hospital Universitario de La Princesa (HULP), Madrid, Spain
| | - Elena Perea
- Division of Gastroenterology and Hepatology, Digestive Motility Unit, IIS-IP and CIBEREHD, Universidad Autónoma de Madrid, Hospital Universitario de La Princesa (HULP), Madrid, Spain
| | - María Caldas
- Division of Gastroenterology and Hepatology, Digestive Motility Unit, IIS-IP and CIBEREHD, Universidad Autónoma de Madrid, Hospital Universitario de La Princesa (HULP), Madrid, Spain
| | - Pere Clave
- Universitat Autònoma de Barcelona, Hospital de Mataró, Barcelona, Spain
| |
Collapse
|
17
|
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.
Collapse
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.
| |
Collapse
|
18
|
Soyer T, Boybeyi Ö, Atasoy P. Selective inhibition of nitric oxide synthase causes increased muscle thickness in rat esophagus. J Pediatr Surg 2015; 50:1112-4. [PMID: 25783303 DOI: 10.1016/j.jpedsurg.2014.10.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/23/2014] [Accepted: 10/24/2014] [Indexed: 12/29/2022]
Abstract
AIM Achalasia is a primary motor dysfunction of esophagus which can be created experimentally by nitric oxide synthase (NOS) inhibition. Although several theories have been suggested, mechanism of increased esophageal muscle thickness in achalasia is still unclear. An experimental study was performed to evaluate the esophageal muscle thickness after selective inhibition of NOS in rats. MATERIALS AND METHODS Wistar albino rats (n=18) weighing 150-200g of both sexes were included in the study. After anesthetization with ketamine hydrochloride, esophageal body and distal esophagus were sampled in control group (CG, n=6). In sham group (SG, n=6), intraperitoneal saline (1ml) injection was performed for 21days. l-NAME (l-nitroarginin metyl ester, selective inhibitor of NOS) group (LNAMEG, n=6) received 100mg/kg/d l-NAME intraperitoneally for 21days. The esophageal body and distal esophagus were removed for histopathological analysis in each group. All samples were evaluated for total and circular muscle thickness with hemotoxylene-eosine (HE) staining. RESULTS None of the samples showed pathologic finding in esophageal mucosa. There was no difference between CG and SG for total and circular muscle thickness in esophageal body and distal esophagus. LNAMEG had higher median levels of both total and circular muscle thickness than CG and SG in esophageal body (P<0.05). However, in distal esophageal segments, only total muscle thickness was statistically higher in LNAMEG than CG and SG (P<0.05). CONCLUSION Selective inhibition of NOS causes increased total smooth muscle thickness in esophageal body and distal esophagus. However, this effect could not detected in circular muscle in the distal esophagus. We suggest that NOS inhbition not only increases esophageal peristalsis but also causes muscle hypertrophy in esophagus.
Collapse
Affiliation(s)
- Tutku Soyer
- Hacettepe University Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey.
| | - Özlem Boybeyi
- Kirikkale University Faculty of Medicine, Department of Pediatric Surgery, Kirikkale, Turkey
| | - Pinar Atasoy
- Kirikkale University Faculty of Medicine, Department of Pathology, Kirikkale, Turkey
| |
Collapse
|
19
|
Singhal V, Khaitan L. Preoperative Evaluation of Gastroesophageal Reflux Disease. Surg Clin North Am 2015; 95:615-27. [DOI: 10.1016/j.suc.2015.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
20
|
Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment. Curr Gastroenterol Rep 2015; 16:421. [PMID: 25376746 DOI: 10.1007/s11894-014-0421-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
Collapse
|
21
|
Abstract
Manometry and impedance provide only surrogate information regarding longitudinal wall function and are focused on contractile amplitude and lumen content. Ultrasound imaging provides a unique perspective of esophageal function by providing important information regarding longitudinal muscle contraction. Laser Doppler assessment of perfusion may be an important complementary tool to assess abnormal wall blood perfusion as a possible mechanism of pain.
Collapse
Affiliation(s)
- Ravinder K. Mittal
- Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, CA, USA
| |
Collapse
|
22
|
Sato H, Inoue H, Ikeda H, Sato C, Santi EGR, Phalanusitthepha C, Aoyagi Y, Kudo SE. In vivo histopathological assessment of the muscularis propria in achalasia by using endocytoscopy (with video). Endosc Int Open 2014; 2:E178-82. [PMID: 26134965 PMCID: PMC4440363 DOI: 10.1055/s-0034-1377319] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/05/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The histopathology of the muscularis propria (MP) is unknown in patients with achalasia. Endocytoscopy (EC) was developed as an ultra-high magnification endoscopy, and the submucosal tunnel created during peroral endoscopic myotomy (POEM) not only provides access to the MP but also enables subsequent endoscopic assessment of the MP. PATIENTS AND METHODS In seven patients with achalasia (mean ± SD; 35 ± 18.1 years; men:women, 4:3) who underwent POEM (myotomy length: 12 ± 2.2 cm), subsequent EC examination was performed from the mid-esophagus to the gastric side. EC images were compared to the results of histopathologic examination (two biopsies from the mid-esophagus and lower esophageal sphincter), which was the standard. RESULTS In all patients, favorable EC images were obtained, and spindle-shaped smooth muscle cells were detected. In our series, we observed no notable features such as atrophy or hypertrophy of smooth muscle cells. In addition, the EC assessment was consistent with the results of biopsy. No complications were encountered during any of the procedures. CONCLUSION In a clinical setting, real-time assessment of the MP using EC is feasible. This technique may play an important role in determining the pathology of achalasia and other diseases that affect gastrointestinal function.
Collapse
Affiliation(s)
- Hiroki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital,
Japan,Corresponding author Hiroki Sato, MD Showa
University Northern Yokohama Hospital - Digestive Disease
CenterChigasaki-chuo
35–1Yokohama
224–8503Japan+81–45–949–7927
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University, Northern Yokohama Hospital,
Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University, Northern Yokohama Hospital,
Japan
| | - Chiaki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital,
Japan
| | | | | | - Yutaka Aoyagi
- Division of Gastroenterology, Niigata University Medical and Dental
Hospital, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University, Northern Yokohama Hospital,
Japan
| |
Collapse
|
23
|
Lin Z, Yim B, Gawron A, Imam H, Kahrilas PJ, Pandolfino JE. The four phases of esophageal bolus transit defined by high-resolution impedance manometry and fluoroscopy. Am J Physiol Gastrointest Liver Physiol 2014; 307:G437-44. [PMID: 24970774 PMCID: PMC4137111 DOI: 10.1152/ajpgi.00148.2014] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We aimed to model esophageal bolus transit based on esophageal pressure topography (EPT) landmarks, concurrent intrabolus pressure (IBP), and esophageal diameter as defined with fluoroscopy. Ten healthy subjects were studied with high-resolution impedance manometry and videofluoroscopy. Data from four 5-ml barium swallows (2 upright, 2 supine) in each subject were analyzed. EPT landmarks were utilized to divide bolus transit into four phases: phase I, upper esophageal sphincter (UES) opening; phase II, UES closure to the transition zone (TZ); phase III, TZ to contractile deceleration point (CDP); and phase IV, CDP to completion of bolus emptying. IBP and esophageal diameter were analyzed to define functional differences among phases. IBP exhibited distinct changes during the four phases of bolus transit. Phase I was associated with filling via passive dilatation of the esophagus and IBP reflective of intrathoracic pressure. Phase II was associated with auxotonic relaxation and compartmentalization of the bolus distal to the TZ. During phase III, IBP exhibited a slow increase with loss of volume related to peristalsis (auxotonic contraction) and passive dilatation in the distal esophagus. Phase IV was associated with the highest IBP and exhibited isometric contraction during periods of nonemptying and auxotonic contraction during emptying. IBP may be used as a marker of esophageal wall state during the four phases of esophageal bolus transit. Thus abnormalities in IBP may identify subtypes of esophageal disease attributable to abnormal distensibility or neuromuscular dysfunction.
Collapse
Affiliation(s)
- Zhiyue Lin
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Brandon Yim
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew Gawron
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Hala Imam
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J. Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
24
|
Krishnan K, Lin CY, Keswani R, Pandolfino JE, Kahrilas PJ, Komanduri S. Endoscopic ultrasound as an adjunctive evaluation in patients with esophageal motor disorders subtyped by high-resolution manometry. Neurogastroenterol Motil 2014; 26:1172-8. [PMID: 25041229 PMCID: PMC4331010 DOI: 10.1111/nmo.12379] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 05/13/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Esophageal motor disorders are a heterogeneous group of conditions identified by esophageal manometry that lead to esophageal dysfunction. The aim of this study was to assess the clinical utility of endoscopic ultrasound (EUS) in the further evaluation of patients with esophageal motor disorders categorized using the updated Chicago Classification. METHODS We performed a retrospective, single center study of 62 patients with esophageal motor disorders categorized according to the Chicago Classification. All patients underwent standard radial endosonography to assess for extra-esophageal findings or alternative explanations for esophageal outflow obstruction. Secondary outcomes included esophageal wall thickness among the different patient subsets within the Chicago Classification. KEY RESULTS EUS identified 9/62 (15%) clinically relevant findings that altered patient management and explained the etiology of esophageal outflow obstruction. We further identified substantial variability in esophageal wall thickness in a proportion of patients including some with a significantly thickened non-muscular layer. CONCLUSIONS & INFERENCES EUS findings are clinically relevant in a significant number of patients with motor disorders and can alter clinical management. Variability in esophageal wall thickness of the muscularis propria and non-muscular layers identified by EUS may also explain the observed variability in response to standard therapies for achalasia.
Collapse
Affiliation(s)
- K Krishnan
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | | | | | | |
Collapse
|
25
|
Krarup AL, Liao D, Gregersen H, Drewes AM, Hejazi RA, McCallum RW, Vega KJ, Frazzoni M, Frazzoni L, Clarke JO, Achem SR. Nonspecific motility disorders, irritable esophagus, and chest pain. Ann N Y Acad Sci 2013; 1300:96-109. [PMID: 24117637 DOI: 10.1111/nyas.12244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This paper presents commentaries on whether Starling's law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic- and gender-based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high-resolution manometry in noncardiac chest pain; whether pH-impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.
Collapse
Affiliation(s)
- Anne Lund Krarup
- Mech-Sense, Department of Gastroenterology, Aalborg University, Aalborg, Denmark
| | - Donghua Liao
- Mech-Sense, Department of Gastroenterology, Aalborg University, Aalborg, Denmark
| | - Hans Gregersen
- Mech-Sense, Department of Gastroenterology, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology, Aalborg University, Aalborg, Denmark
| | - Reza A Hejazi
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Richard W McCallum
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Kenneth J Vega
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Marzio Frazzoni
- Fisiopatologia Digestiva, Nuovo Ospedale S. Agostino, Modena, Italy
| | | | - John O Clarke
- Division of Gastroenterology, Johns Hopkins University, Baltimore, Maryland
| | - Sami R Achem
- Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
26
|
Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108:1238-49; quiz 1250. [PMID: 23877351 DOI: 10.1038/ajg.2013.196] [Citation(s) in RCA: 331] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.
Collapse
Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37232-5280, USA.
| | | | | |
Collapse
|
27
|
Kim JH, Choi YS, Kim JJ, Rhee JC, Rhee PL. Characteristics of esophageal proper muscle in patients with non-cardiac chest pain using high-frequency intraluminal ultrasound. J Gastroenterol Hepatol 2013; 28:488-93. [PMID: 22989117 DOI: 10.1111/j.1440-1746.2012.07263.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2012] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM It is unclear which mechanisms play a predominant role in the pathogenesis of esophageal non-cardiac chest pain (NCCP). We aimed to examine the features of esophageal proper muscle and esophageal contractility using a high-frequency intraluminal ultrasound (HFIUS) in patients with NCCP. METHODS A total of 68 patients with NCCP were classified into two groups according to the results of typical reflux symptoms and/or esophagogastroduodenoscopy and/or 24-h esophageal pH monitoring: gastroesophageal reflux disease (GERD)-positive NCCP (n = 34) and GERD-negative NCCP groups (n = 34). Additionally 16 asymptomatic healthy subjects were included as controls. Using HFIUS, we analyzed the esophageal proper muscle thickness and cross-sectional area (CSA) at 3 cm above lower esophageal sphincter (LES) and 9 cm above LES during baseline rest and peak contraction periods among the control, GERD-positive NCCP and GERD-negative NCCP groups, and examined the completeness of three phases of esophageal action during five wet swallows in the three groups. RESULTS The muscle thickness and CSA tended to be larger in GERD-negative NCCP than in GERD-positive NCCP and in control groups at esophageal body during both periods. All of the controls and patients with GERD-positive NCCP presented the complete peristaltic type. Whereas, 11 of 34 patients with GERD-negative NCCP presented the incomplete peristaltic type. CONCLUSIONS Using HFIUS, patients with GERD-negative NCCP had increased muscle thickness and CSA. Some GERD-negative NCCP had the incomplete peristaltic type.
Collapse
Affiliation(s)
- Jeong Hwan Kim
- Department of Internal Medicine, Digestive Disease Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | | | | | | | | |
Collapse
|
28
|
Abstract
Dysphagia is common in the general population, and is generally due to either mechanical obstruction or dysmotility. Patient demographics and symptom evaluation are often useful in determining the likely cause, and guide subsequent investigation and management. Oropharyngeal dysphagia is usually caused by neurological conditions where treatment options are limited. Conversely, many of the esophageal causes of dysphagia are amenable to therapy. Gastroscopy is often the first test of choice, given its diagnostic and therapeutic potential, especially when mechanical causes are concerned. Esophageal motor function can be assessed by a variety of techniques, ranging from radiology such as barium swallow, to dedicated motility tests such as manometry and impedance monitoring. The choice of test relies on the clinical indication and the results should be interpreted in conjunction with the patients' symptoms. High-resolution manometry with topography is now the new benchmark for motility studies. Several new techniques for motility testing have also become available, such as esophageal ultrasound and functional lumen imaging probe, but are currently limited to the research setting.
Collapse
Affiliation(s)
- Paul Kuo
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | |
Collapse
|
29
|
Akiho H, Ihara E, Motomura Y, Nakamura K. Cytokine-induced alterations of gastrointestinal motility in gastrointestinal disorders. World J Gastrointest Pathophysiol 2011; 2:72-81. [PMID: 22013552 PMCID: PMC3196622 DOI: 10.4291/wjgp.v2.i5.72] [Citation(s) in RCA: 68] [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: 03/31/2011] [Revised: 08/12/2011] [Accepted: 08/19/2011] [Indexed: 02/06/2023] Open
Abstract
Inflammation and immune activation in the gut are usually accompanied by alteration of gastrointestinal (GI) motility. In infection, changes in motor function have been linked to host defense by enhancing the expulsion of the infectious agents. In this review, we describe the evidence for inflammation and immune activation in GI infection, inflammatory bowel disease, ileus, achalasia, eosinophilic esophagitis, microscopic colitis, celiac disease, pseudo-obstruction and functional GI disorders. We also describe the possible mechanisms by which inflammation and immune activation in the gut affect GI motility. GI motility disorder is a broad spectrum disturbance of GI physiology. Although several systems including central nerves, enteric nerves, interstitial cells of Cajal and smooth muscles contribute to a coordinated regulation of GI motility, smooth muscle probably plays the most important role. Thus, we focus on the relationship between activation of cytokines induced by adaptive immune response and alteration of GI smooth muscle contractility. Accumulated evidence has shown that Th1 and Th2 cytokines cause hypocontractility and hypercontractility of inflamed intestinal smooth muscle. Th1 cytokines downregulate CPI-17 and L-type Ca2+ channels and upregulate regulators of G protein signaling 4, which contributes to hypocontractility of inflamed intestinal smooth muscle. Conversely, Th2 cytokines cause hypercontractilty via signal transducer and activator of transcription 6 or mitogen-activated protein kinase signaling pathways. Th1 and Th2 cytokines have opposing effects on intestinal smooth muscle contraction via 5-hydroxytryptamine signaling. Understanding the immunological basis of altered GI motor function could lead to new therapeutic strategies for GI functional and inflammatory disorders.
Collapse
|
30
|
Kawai T, Yamagishi T. Comparison of investigation modalities for evaluation of esophageal peristaltic function. J Clin Biochem Nutr 2011; 42:185-90. [PMID: 18545639 PMCID: PMC2386520 DOI: 10.3164/jcbn.2008027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2007] [Accepted: 01/08/2008] [Indexed: 11/22/2022] Open
Abstract
We reviewed the recent literature concerning investigations of esophageal peristaltic function. The gold standard for the assessment of esophageal peristaltic function is manometry with pH monitoring. Even with this investigation modality, however, we are in fact doing no more than estimating esophageal peristaltic function from the manometry and pH results. With esophageal fluoroscopy and scintigraphy, where we observe esophageal motility, there are problems with radiation exposure and handling of radioactive agents that make widespread use difficult. In recent years, the development of multichannel intraluminal impedance (MII) manometry has allowed simultaneous measurement of intraesophageal pressure and assessment of esophageal peristalsis. Using MII it is also possible to distinguish whether gas or liquid is passing down the esophagus. When manometry is performed in conjunction with transnasal esophagogastroduodenoscopy, with this unique combination it is possible to measure the intraesophageal pressure while actually observing the swallowing motion at the same time. Assessment of esophageal peristaltic function is now moving from simple measurement of intraesophageal pressure to simultaneous impedance manometry and endoscopic observation of esophageal peristalsis itself.
Collapse
Affiliation(s)
- Takashi Kawai
- Endoscopy Center, Tokyo Medical University Hospital, Shinjuku-ku, Tokyo 160-0023, Japan
| | | |
Collapse
|
31
|
Krieger-Grübel C, Hiscock R, Nandurkar S, Heddle R, Hebbard G. Physiology of diffuse esophageal spasm (DES)--when normal swallows are not normal. Neurogastroenterol Motil 2010; 22:1056-e279. [PMID: 20565688 DOI: 10.1111/j.1365-2982.2010.01540.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diffuse esophageal spasm (DES) is characterized on manometry by a combination of simultaneous contractions and normal swallows. The aim of this study was to examine the manometric characteristics of simultaneous and 'normal' swallows in patients with DES patients compared with normal controls. METHODS Manometric studies from 69 patients with DES and 20 controls were analysed to determine the proportion of normal, hypertensive, ineffective and simultaneous contractions, and the velocity of propagation along the esophagus, the duration and amplitude of contraction and the relaxation characteristics (nadir and duration) of the lower esophageal sphincter. KEY RESULTS The propagation velocity was the only significant difference between normal swallows and simultaneous contractions in DES patients (middle third: 49.2 VS 101.2 mm s(-1), P ≤ 0.001 lower third: 44.1 VS 88.7 mm s(-1), P ≤ 0.001). 'Normal' swallows in patients with DES had a greater velocity of propagation than those in age-matched control subjects (middle third: 49.2 VS 37.0 mm s(-1), P = 0.02, lower third: 44.1 VS 23.3 mm s(-1), P ≤ 0.001). CONCLUSIONS & INFERENCES As expected, simultaneous contractions of DES patients differ from 'normal' swallows in DES patients mainly regarding the velocity of propagation of contraction but are similar in amplitude, however 'normal' swallows of DES patients are also more rapidly propagated along the esophagus than normal swallows of a control group suggesting that all swallows in DES are affected to some degree by the same process.
Collapse
Affiliation(s)
- C Krieger-Grübel
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia.
| | | | | | | | | |
Collapse
|
32
|
Abstract
Diffuse esophageal spasm is a primary esophageal motility disorder. The prevalence is 3-10% in patients with dysphagia and treatment options are limited. This review summarizes the treatment of diffuse esophageal spasm, including pharmacotherapy, endoscopic treatment, and surgical treatment with a special focus on botulinum toxin injection. A PubMed search was performed to identify the literature using the search items diffuse esophageal spasm and treatment. Pharmacotherapy with smooth muscle relaxants, proton pump inhibitors, and antidepressants was suggested from small case series and uncontrolled clinical trials. Endoscopic injection of botulinum toxin is a well-studied treatment option and results in good symptomatic benefit in patients with diffuse esophageal spasm. Surgical treatment was reported in patients with very severe symptoms refractory to pharmacologic treatment. This article summarizes the present knowledge on the treatment of diffuse esophageal spasm with a special emphasis on botulinum toxin injection. Endoscopic injection of botulinum toxin is presently the best studied treatment option but many questions remain unanswered.
Collapse
Affiliation(s)
- M Bashashati
- Division of Gastroenterology, Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, Canada
| | | | | | | |
Collapse
|
33
|
Sinn DH, Choi YS, Kim JH, Kim ER, Son HJ, Kim JJ, Rhee JC, Rhee PL. Change in cross-sectional area of esophageal muscle does not correlate with the outcome of achalasia after pneumatic balloon dilatation. J Gastroenterol Hepatol 2010; 25:539-43. [PMID: 20370731 DOI: 10.1111/j.1440-1746.2009.06108.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Patients with achalasia have a thicker muscularis propria compared to normal patients. Because pneumatic balloon dilatation (PD) is an effective treatment for achalasia, the changes in the esophageal muscles after PD may predict treatment outcomes, if muscular change is of primary importance. In the present study, we aimed to observe the changes in esophageal muscle thickness following PD and assessed whether symptom relapse can be predicted on the basis of the esophageal muscle cross-sectional area (CSA), as measured by high-frequency intraluminal ultrasound (HFIUS). METHODS Fifteen patients treated by PD were studied and followed up for a median of 3.6 years. An HFIUS was done before PD and 6 months after PD. The esophageal muscle CSA measured at the lower esophageal sphincter (LES), and 3 and 6 cm above the LES, was used to see whether any association was present between symptom recurrence and the esophageal muscle CSA. RESULTS A single PD resulted in a 2-year remission rate of 66%. A significance variance in change (-65%-248%) was noticed in the muscle CSA after PD. The predilation muscle CSA, post-dilation muscle CSA, and change in the muscle CSA after PD was not associated with symptom recurrence. CONCLUSION Our findings suggest that measuring the muscle CSA does not help to predict treatment outcome. Muscular changes in achalasia might be just reactive changes.
Collapse
Affiliation(s)
- Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
INTRODUCTION Achalasia is a primary oesophageal motility disorder resulting from damage to the ganglion cells of the myenteric plexus. Impaired relaxation of the lower oesophageal sphincter and aperistalsis causes its cardinal symptoms of dysphagia, chest pain and reflux-type symptoms. Management is somewhat controversial, with options including systemic and local pharmacotherapy, dilatation and oesophagomyotomy. We review the presentation, investigation and management of oesophageal achalasia and make an argument for primary surgical management. METHODS We performed a Medline search of the term 'achalasia', limiting the search to clinical trials and meta-analyses. We then selected articles based on their abstracts using four main criteria: previously unreported findings, previously unreported techniques, size of patient cohort and journal impact factor. References in selected articles were manually searched for other relevant articles. FINDINGS Achalasia has been managed using a variety of techniques including systemic and local pharmacotherapy, forced dilatation and oesophagomyotomy. Success rates vary widely between techniques. Mechanical disruption ofthe lower oesophageal sphincter is most successful. DISCUSSION In achalasia, mechanical disruption of the lower oesophageal sphincter using forced dilatation or surgical myotomy offers the only realistic prospect of long-term symptom relief. Recent evidence suggests that previous medical treatment or dilatation makes oesophagomyotomy more difficult and increases the risk of complications. As the morbidity associated with surgery continues to decrease with improvements in minimal access techniques, the argument for primary management of achalasia with oesophagomyotomy becomes more compelling.
Collapse
Affiliation(s)
- D S Leonard
- Department of Surgery Beaumont Hospital, Dublin, Ireland.
| | | |
Collapse
|
35
|
Sifrim D, Blondeau K, Mantillla L. Utility of non-endoscopic investigations in the practical management of oesophageal disorders. Best Pract Res Clin Gastroenterol 2009; 23:369-86. [PMID: 19505665 DOI: 10.1016/j.bpg.2009.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The current available methods for diagnosis of GORD are symptom questionnaires, catheter and wireless pH-metry, impedance-pH monitoring and Bilitec(@). Osophageal pH monitoring allows both quantitative analysis of acid reflux and assessment of reflux-symptom association. Impedance-pH monitoring detects all types of reflux (acid and non-acid) and allows assessment of proximal extent of reflux, a relevant parameter for understanding symptoms perception and extraoesophageal symptoms. Bilitec provides a quantitative assessment of duodeno-gastro-oesophageal reflux. Oesophageal motor abnormalities have been associated with GORD symptoms as well as chest pain and dysphagia. High-resolution manometry contributed to re-classify oesphageal motor disorders. However, barium swallows are still essential for evaluation of oesophageal anatomy and combined oesophageal manometry-impedance can assess oesophageal motility and bolus transit simultaneously in a non-radiological way. Still in experimental phase, high-frequency ultrasound allows monitoring of the oesophageal wall thickness and exaggerated longitudinal muscle contraction that might be associated to chest pain and dysphagia. This chapter provides a critical evaluation of the clinical application of these techniques.
Collapse
Affiliation(s)
- Daniel Sifrim
- Center for Gastroenterological Research, Catholic University of Leuven, Belgium.
| | | | | |
Collapse
|
36
|
Abstract
OBJECTIVE The purpose of this study was to determine the frequency and appearance of esophageal wall thickening on CT scans in a series of patients with findings of diffuse esophageal spasm on barium studies. CONCLUSION CT revealed marked esophageal wall thickening in seven (21%) of 33 patients who had findings of diffuse esophageal spasm on barium studies. CT showed significantly greater esophageal wall thickening in the lower thoracic esophagus 5 cm above the gastroesophageal junction than in the upper thoracic esophagus at the level of the aortic arch or in the midthoracic esophagus at the level of the carina (p < 0.01). This esophageal wall thickening corresponded to the presence of multiple strong nonperistaltic contractions in the lower thoracic esophagus on barium studies. Our findings suggest that diffuse esophageal spasm should be included in the differential diagnosis when CT shows smooth circumferential wall thickening in the lower half of the thoracic esophagus, particularly in elderly patients with dysphagia or chest pain.
Collapse
|
37
|
Is all ineffective esophageal motility the same? A clinical and high-frequency intraluminal US study. Gastrointest Endosc 2008; 68:422-31. [PMID: 18378232 DOI: 10.1016/j.gie.2007.11.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 11/12/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ineffective esophageal motility (IEM) is characterized by frequent hypotensive or failed peristaltic contractions; its pathophysiology is controversial. OBJECTIVE To evaluate whether patients with IEM because of GERD would differ from patients with other etiologies of IEM on the basis of esophageal-muscle thickness measured by high-frequency intraluminal US (HFIUS). DESIGN Single-center prospective study. SETTING Academic medical center; from January 2004 to June 2005. SUBJECTS A total of 46 patients who were newly diagnosed with IEM were classified into 2 groups: GERD-related IEM (group I, n = 26) and non-GERD-related IEM (group II, n = 20) on the basis of the presence of reflux esophagitis and/or pathologic acid exposure by 24-hour esophageal pH monitoring. In addition, 16 asymptomatic healthy volunteers with no reflux esophagitis, normal manometric finding, and normal level of acid exposure were included as controls. MAIN OUTCOME MEASUREMENTS We compared the clinical characteristics, including a predominant principal esophageal symptom and the results from HFIUS among the control, GERD-related IEM (group I), and non-GERD-related IEM (group II) groups. RESULTS The proportion of typical reflux symptom as a predominant symptom was higher in group I (66%) than in group II (25%). Muscle thickness was greater in group II than in group I and the control group during both the baseline rest period and the peak of contraction period at all levels of the middle of the lower esophageal sphincter (LES), and 3 cm and 9 cm above the LES (respectively) (P < .05). LIMITATION The limitation was the small sample size. CONCLUSIONS Patients with non-GERD-related IEM had increased muscle thickness on HFIUS compared with patients with GERD-related IEM and the controls. Based on this study, IEM is not necessarily indicative of GERD.
Collapse
|
38
|
Korsapati H, Bhargava V, Mittal RK. Reversal of asynchrony between circular and longitudinal muscle contraction in nutcracker esophagus by atropine. Gastroenterology 2008; 135:796-802. [PMID: 18675815 DOI: 10.1053/j.gastro.2008.05.082] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/22/2008] [Accepted: 05/29/2008] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Patients with high-amplitude esophageal contractions (nutcracker esophagus [NCE]) show asynchrony of circular muscle (CM) and longitudinal muscle (LM) contraction during peristalsis. The goal of our study was to determine if this asynchrony is related to an increase in the cholinergic receptor activity. METHODS High-frequency intraluminal ultrasound images and pressures of the esophagus were recorded simultaneously in 10 normal subjects and 10 patients with NCE. Recordings were obtained at 2 cm above the lower esophageal sphincter under 2 study conditions in normal subjects (before and after 80 microgm/kg of edrophonium), and under 3 study conditions in the NCE patients (control, 5 microgm and 10 microgm/kg of atropine). RESULTS In normal subjects, edrophonium induced an increase in the CM and LM contraction amplitude, an increase in the contraction duration, and asynchrony of LM and CM contraction during peristalsis. On the other hand, increased contraction amplitude, duration, and asynchrony of LM and CM contraction observed at the baseline in the NCE patients were reversed by atropine in a dose-dependent fashion. CONCLUSIONS These data prove that the esophageal motor abnormalities in patients with nutcracker esophagus, including asynchrony of CM and LM contraction, are related to a hypercholinergic state.
Collapse
Affiliation(s)
- Hariprasad Korsapati
- Division of Gastroenterology, San Diego VA Health Care System, San Diego, California 92161, USA
| | | | | |
Collapse
|
39
|
Fornari F, Farré R, van Malenstein H, Blondeau K, Callegari-Jacques SM, Barros SGS. Nutcracker oesophagus: association with chest pain and dysphagia controlling for gastro-oesophageal reflux. Dig Liver Dis 2008; 40:717-22. [PMID: 18394977 DOI: 10.1016/j.dld.2008.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 02/12/2008] [Accepted: 02/14/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND The association between nutcracker oesophagus, gastro-oesophageal reflux and their symptoms is controversial. AIM To evaluate the association of nutcracker oesophagus with chest pain and dysphagia controlling for gastro-oesophageal reflux. METHODS From a database of 935 consecutive patients investigated with oesophageal manometry and pH-metry, we selected all patients with nutcracker oesophagus including diffuse and segmental patterns. Patients with normal oesophageal peristalsis served as controls. Symptoms assessment, manometry testing and 24h oesophageal pH monitoring off acid-suppressive medications were performed following a standardized protocol. The associations between nutcracker oesophagus and symptoms were assessed by logistic regression analysis. RESULTS Nutcracker oesophagus was found in 60 patients (6.4%), of which 30 had diffuse nutcracker oesophagus and 30 had segmental nutcracker oesophagus. The control group was composed by 656 patients with normal oesophageal peristalsis. Diffuse nutcracker oesophagus was associated with chest pain (odds ratio 4.3; 95% CI 1.9-9.9; P<0.0001) and dysphagia (odds ratio 5.3; 95% CI 2.3-12.2; P<0.0001), whereas segmental nutcracker oesophagus was associated with chest pain (odds ratio 2.8; 95% CI 1.1-6.9; P=0.026), controlling for total oesophageal acid exposure, age, sex and lower oesophageal sphincter (LOS) pressure. CONCLUSION This study suggests that both diffuse and segmental nutcracker oesophagus should be regarded as meaningful abnormalities and not mere manometric curiosities.
Collapse
Affiliation(s)
- F Fornari
- Laboratory of Esophageal Motility, ENDOPASSO, Passo Fundo/RS, Brazil.
| | | | | | | | | | | |
Collapse
|
40
|
Kim HS, Park H, Lim JH, Choi SH, Park C, Lee SI, Conklin JL. Morphometric evaluation of oesophageal wall in patients with nutcracker oesophagus and ineffective oesophageal motility. Neurogastroenterol Motil 2008; 20:869-76. [PMID: 18452508 DOI: 10.1111/j.1365-2982.2008.01128.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The pathogenesis of nutcracker oesophagus (NE) and ineffective oesophageal motility (IEM) is unclear. Damage to the enteric nervous system or smooth muscle can cause oesophageal dysmotility. We tested the hypothesis that NE and IEM are associated with abnormal muscular or neural constituents of the oesophageal wall. Oesophageal manometry was performed in patients prior to total gastrectomy for gastric cancer. The oesophageal manometries were categorized as normal (n = 7), NE (n = 13), or IEM (n = 5). Histologic examination of oesophageal tissue obtained during surgery was performed after haematoxylin and eosin (H&E) and trichrome staining. Oesophageal innervation was examined after immunostaining for protein gene product-9.5 (PGP-9.5), choline acetyltransferase (ChAT) and neuronal nitric oxide synthase (nNOS). There were no significant differences in inner circular smooth muscle thickness or degree of fibrosis among the three groups. Severe muscle fibre loss was found in four of five patients with IEM. The density of PGP-9.5-reactive neural structures was not different among the three groups. The density of ChAT immunostaining in the myenteric plexus (MP) was significantly greater in patients with NE (P < 0.05) and the density of nNOS immunostaining in the circular muscle (CM) was significantly greater in IEM patients (P < 0.05). The ChAT/nNOS ratio in both MP and CM was significantly greater in NE patients. NE may result from an imbalance between the excitatory and inhibitory innervation of the oesophagus, because more than normal numbers of ChAT-positive myenteric neurones are seen in NE. Myopathy and/or increased number of nNOS neurones may contribute to the hypocontractile motor activity of IEM.
Collapse
Affiliation(s)
- H S Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | |
Collapse
|
41
|
Facco M, Brun P, Baesso I, Costantini M, Rizzetto C, Berto A, Baldan N, Palù G, Semenzato G, Castagliuolo I, Zaninotto G. T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens. Am J Gastroenterol 2008; 103:1598-609. [PMID: 18557707 DOI: 10.1111/j.1572-0241.2008.01956.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The loss of myenteric neurons in the lower esophageal sphincter (LES) characterizes achalasia, an esophageal motor disorder. Because the presence of lymphocytic infiltrates suggests an immuno-mediated mechanism ongoing at the sites of disease, we investigated the T-cell receptor (TCR) repertoire and the ability to recognize human herpes virus type 1 (HSV-1) antigens of LES-infiltrating T lymphocytes in achalasia patients. METHODS Fifty-nine patients with idiopathic achalasia and 38 heart-beating cadaveric multiorgan donors (controls) were studied. By flow cytometry evaluation and CDR3 length spectratyping analysis, the lymphocytes of 18 patients and 15 controls were analyzed, whereas 41 patients and 23 controls were employed for functional assays. RESULTS Achalasia patients were characterized by a significantly higher esophagus lymphocytic infiltrate than controls (24.71%+/- 3.11 and 9.54%+/- 1.34, respectively; P < 0.05), mainly represented by CD3+CD8+ T cells. The characterization of TCR beta chain repertoire of CD3+ cells showed the expression of a limited number of TCR beta variable (BV) gene families (from two to five out of 26), with highly restricted spectratypes, suggesting a disease-associated oligoclonal selection of T cells. Furthermore, lymphocytes from achalasia LES specifically responded to exposure to HSV-1 antigens in vitro as showed by increased proliferation and Th-1 type cytokines release. CONCLUSIONS These data suggest that the oligoclonal lymphocytic infiltrate within the LES of achalasia patients may represent the trace of an immune-inflammatory reaction triggered by HSV-1 antigens and that the Th1-type cytokines released by the activated lymphocytes may contribute to establish the neuronal damage accounting for the clinical features of idiopathic achalasia.
Collapse
Affiliation(s)
- Monica Facco
- Department of Clinical and Experimental Medicine, Hematology and Clinical Immunology Branch, Padua University School of Medicine, Padova, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
In 1987, Richter and colleagues published the results of an esophageal motility study conducted on 95 normal healthy volunteers between the ages of 22 and 79. In accordance with these results, abnormal esophageal motility was defined on the basis of the percentage of manometric normal, ineffective, and simultaneous swallows and on lower esophageal sphincter dynamics during liquid swallows. For example, Richter and colleagues found that the mean amplitude of contraction in the distal body of the esophagus >180 mm Hg in association with wet swallows was above the 95% confidence interval of normal. Richter's study also showed a wide variation among individuals and that the mean distal esophageal contractile amplitude increased with age without sex predominance. Likewise, as no subjects had >20% simultaneous contractions (though a considerable number, 4%, had 10% simultaneous contractions), esophageal spasm was defined at the >20% mark.
Collapse
|
43
|
Abstract
The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.
Collapse
Affiliation(s)
- Claudia Grübel
- Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | | | | | | | | |
Collapse
|
44
|
Kacar S, Uysal S, Kuran S, Dagli U, Ozin Y, Karabulut E, Sasmaz N. Transcutaneous cervical esophagus ultrasound in adults: Relation with ambulatory 24-h pH-monitoring and esophageal manometry. World J Gastroenterol 2007; 13:5245-52. [PMID: 17876896 PMCID: PMC4171307 DOI: 10.3748/wjg.v13.i39.5245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the gastroesophageal refluxate in the cervical esophagus (CE) and measure transcutaneous cervical esophageal ultrasound (TCEUS) findings [anterior wall thickness (WT) of CE, esophageal luminal diameter (ELD), esophageal diameter (ED)]; to compare TCEUS findings in the patient subgroups divided according to 24-h esophageal pH monitoring and manometry; and to investigate possible cut-off values according to the TCEUS findings as a predictor of gastroesophageal reflux (GER).
METHODS: In 45/500 patients, refluxate was visualized in TCEUS. 38/45 patients underwent esophagogastroduodenoscopy (EGD), 24-h pH monitoring and manometry.
RESULTS: The 38 patients were grouped according to 24-h pH monitoring as follows: Group A: GER-positive (n = 20) [Includes Group B: isolated proximal reflux (PR) (n = 6), Group C: isolated distal reflux (DR) (n = 6), and Group D: both PR/DR (n = 8)]; Group E: no reflux (n = 13); and Group F: hypersensitive esophagus (HSE) (n = 5). Groups B + D indicated total PR patients (n = 14), Groups E + F reflux-negatives with HSE (n = 18), and Groups A + F reflux-positives with HSE (n = 25). When the 38 patients were grouped according to manometry findings, 24 had normal esophageal manometry; 7 had hypotensive and 2 had hypertensive lower esophageal sphincter (LES); and 5 had ineffective esophageal motility disorder (IEM). The ELD measurement was greater in group A + F than group E (P = 0.023, 5.0 ± 1.3 vs 3.9 ± 1.4 mm). In 27/38 patients, there was at least one pathologic acid reflux and/or pathologic manometry finding. The cut-off value for ELD of 4.83 mm had 79% sensitivity and 61% specificity in predicting the PR between Groups B + D and E (AUC = 0.775, P = 0.015).
CONCLUSION: Visualizing refluxate in TCEUS was useful as a pre-diagnostic tool for estimating GER or manometric pathology in 71.1% of adults in our study, but it was not diagnostic for CE WT.
Collapse
Affiliation(s)
- Sabite Kacar
- Gastroenterology Department, Turkiye Yuksek Ihtisas Hospital, Dikmen Cad 220/A, No 17 Dikmen, Ankara, Turkey
| | | | | | | | | | | | | |
Collapse
|
45
|
Hirano I, Pandolfino J. New technologies for the evaluation of esophageal motility disorders: impedance, high-resolution manometry, and intraluminal ultrasound. Gastroenterol Clin North Am 2007; 36:531-51, viii. [PMID: 17950437 DOI: 10.1016/j.gtc.2007.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
New technologies have been introduced for studying esophageal function, including intraluminal impedance and ultrasound, whereas conventional techniques, such as manometry, have undergone substantial upgrades because of advances in transducer technology, computerization, and graphic data presentation. Although these techniques provide both novel and more detailed information regarding esophageal function, it is still unclear whether they have improved the ability to diagnose and treat patients more effectively. Regardless, they are innovative research tools and they have added substantially to the understanding of the pathophysiology of dysphagia and esophageal motor dysfunction. This article describes the technical aspects of each of these technologies and the potential benefits they offer over conventional techniques for the evaluation of esophageal motor diseases.
Collapse
Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA.
| | | |
Collapse
|
46
|
Abstract
Motor abnormalities of the oesophagus are characterised by a chronic impairment of the neuromuscular structures that co-ordinate oesophageal function. The best-defined entity is achalasia, which is discussed in a separate chapter. Other motor disorders with clinical relevance include diffuse oesophageal spasm, oesophageal dysmotility associated with scleroderma, and ineffective oesophageal motility. These non-achalasic motor disorders have variable prevalence but they could be associated with invalidating symptoms such as dysphagia, chest pain and gastro-oesophageal reflux disease. New oesophageal diagnostic techniques, including high-resolution manometry, high-frequency intraluminal ultrasound and intraluminal impedance, allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce normal or abnormal patterns of bolus transport. This chapter discusses recent advances in physiology, pathophysiology, diagnosis and treatment of non-achalasic oesophageal motor disorders.
Collapse
Affiliation(s)
- Daniel Sifrim
- Centre for Gastroenterological Research, Catholic University of Leuven, Faculty of Medicine, Belgium.
| | | |
Collapse
|
47
|
Silva LFD, de Oliveira Lemme EM. Are there any differences between nutcracker esophagus with and without reflux? Dysphagia 2007; 22:245-50. [PMID: 17457546 DOI: 10.1007/s00455-007-9081-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 01/29/2007] [Indexed: 11/25/2022]
Abstract
"Nutcracker esophagus" (NE) is a primary esophageal motor disorder, first described in patients with noncardiac chest pain. In recent years NE has been associated with gastroesophageal reflux disease (GERD). In this study we compare patients with NE with and without GERD, as defined by pHmetry or endoscopy, with respect to clinical, endoscopic, radiologic, and manometric findings. Fifty-two patients with NE were studied. They were divided in two groups: GERD (17-32.6%) and non-GERD (35-67.4%) patients. Females predominated in both groups, with no significant difference in age (p>0.05). Chest pain was the chief complaint in both groups (p>0.05). Clinical findings in patients with and without reflux included chest pain (52.9% and 51.4%), dysphagia (58.8% and 42.8%), and heartburn (64.7% and 42.8%), followed by regurgitation, dyspepsia, ear, nose, and throat (ENT) complaints, respiratory symptoms, and odynophagia (p>0.05). Erosive esophagitis was found in three patients (5.7%). There were no differences between groups in the findings of barium swallow studies and all manometric findings were similar for both groups (p>0.05). We conclude that there were no differences in patients with NE with or without associated reflux disease. It is important to diagnose reflux properly so patients can be treated adequately.
Collapse
Affiliation(s)
- Luiz Filipe Duarte Silva
- Gastroenterology Division, University Hospital Clementino Fraga Filho, Medicine Faculty, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | |
Collapse
|
48
|
Dogan I, Puckett JL, Padda BS, Mittal RK. Prevalence of increased esophageal muscle thickness in patients with esophageal symptoms. Am J Gastroenterol 2007; 102:137-45. [PMID: 17266691 DOI: 10.1111/j.1572-0241.2006.01003.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with achalasia, diffuse esophageal spasm (DES), and nutcracker esophagus have a thicker muscularis propria than normal subjects. The goal of our study was to determine the prevalence of increased muscle thickness in a group of unselected patients referred to the esophageal function laboratory for evaluation of the symptoms. METHODS We studied 40 normal subjects and 94 consecutive patients. Manometry and ultrasound images were recorded concurrently, using a special custom-built catheter. Esophageal muscle thickness and muscle cross-sectional area were measured at 2 and 10 cm above the lower esophageal sphincter (LES). Patients were assigned manometric diagnosis and determination was made if they had increased muscle thickness and muscle cross-sectional area. RESULTS Nearly all patients with well-defined spastic motor disorders, i.e., achalasia, DES, and nutcracker esophagus, revealed (a) an increase in the muscle thickness/cross-sectional area, (b) increase in esophageal muscle thickness/cross-sectional area was also seen, albeit at a lower prevalence rate, in patients with less well-characterized manometric abnormalities, i.e., hypertensive LES, impaired LES relaxation, and ineffective esophageal motility, and (c) 24% of patients with esophageal symptoms but normal manometry were also found to have an increase in muscle thickness/cross-sectional area. Dysphagia was more likely, and heartburn less likely in patients with increased muscle thickness, but there were no differences in chest pain and regurgitation symptoms between the groups. CONCLUSION We describe, for the first time, increased muscle thickness in patients with esophageal symptoms and normal manometry. We suggest that increased esophageal muscle thickness is likely to be an important marker of esophageal motor dysfunction.
Collapse
Affiliation(s)
- Ibrahim Dogan
- Division of Gastroenterology, University of California, San Diego, San Diego VA HealthCare System, San Diego, California 92161, USA
| | | | | | | |
Collapse
|
49
|
Abstract
Esophageal manometry has long been the gold standard for assessment of esophageal motility. Recently, high-frequency intraluminal ultrasonography (HFIUS) has been introduced to measure esophageal contractility and the thickness of esophageal muscle. Greater esophageal muscle thickness has been reported in patients with achalasia, diffuse spasm, and hypertensive peristalsis. In this issue of the Journal, Mittal and colleagues report additional observations in patients with esophageal symptoms referred for esophageal manometry. Their findings confirm earlier observations in patients with spastic motor disorders and report new findings of greater muscle thickness in patients with nonspecific motor disorders as well as normal manometry. Greater muscle thickness was associated with a greater prevalence of dysphagia suggesting the possibility that symptoms may be related, at least in part, to alterations in the biomechanics of the esophagus. The place of HFIUS in the assessment of esophageal function remains to be determined, but it offers the possibility of greater insights into esophageal physiology as well as clinical esophageal motor disorders.
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW The aim of this article is to highlight literature published during the last year in the context of previous knowledge. RECENT FINDINGS A number of novel techniques - high-resolution manometry, esophageal electrical impedance and intra-luminal ultrasound imaging - have improved our understanding of esophageal function in health and disease. Several studies address the function of longitudinal muscle layer of the esophagus in normal subjects and patients with motor disorders of the esophagus. Esophageal electrical impedance recordings reveal abnormal transit in patients with diffuse esophageal spasm, achalasia and patients with normal manometry. Loss of the mammalian Sprouty2 gene leads to enteric neuronal hyperplasia and esophageal achalasia. Several studies showed excellent long-term results of medical and surgical treatment of achalasia of the esophagus. For the first time, mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients are reported. Novel pharmacologic strategies in the treatment of reflux disease are highlighted. SUMMARY Several novel techniques, perfected during recent years, have improved our understanding of esophageal function and dysfunction. A number of important observations, reviewed here, provide important insight into the pathogenesis of esophageal motor disorders and treatment of gastroesophageal reflux disease.
Collapse
Affiliation(s)
- Ibrahim Dogan
- Division of Gastroenterology, San Diego VA Medical Center and University of California San Diego, San Diego, California, USA
| | | |
Collapse
|