Achalasia: physiology and diagnosis

Clinical and manometric results of peroral endoscopic myotomy in patients with achalasia: experience in a latin american reference center

INTRODUCTION

Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM).

PRIMARY OUTCOME

Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia.

METHODS

Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables.

RESULTS

29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238).

CONCLUSION

Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis

INTRODUCTION

Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients.

MATERIAL AND METHODS

In this study, consecutive achalasia patients undergoing LHM at the University Hospital 'Federico II' of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM).

RESULTS

In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047).

CONCLUSIONS

Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.

Imbalance of Innate and Adaptive Immunity in Esophageal Achalasia

Background/Aims

Previous studies reveal that immune-mediated neuroinflammation plays a key role in the etiology of esophageal achalasia. However, the understanding of leucocyte phenotype and proportion is limited. This study aim to evaluate the phenotypes of leukocytes and peripheral blood mononuclear cells transcriptomes in esophageal achalasia.

Methods

We performed high-dimensional flow cytometry to identified subsets of peripheral leukocytes, and further validated in lower esophageal sphincter histologically. RNA sequencing was applied to investigate the transcriptional changes in peripheral blood mononuclear cells of patients with achalasia. Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) was used for estimating the immune cell types. A differential gene expression analysis was performed and the differential expressed genes were subjected to gene ontology, Kyoto Encyclopedia of Genes and Genomes network, protein-protein interaction network construction.

Results

An imbalance between innate and adaptive immune cells occurred in achalasia. Specifically, neutrophils and CD8+ T cells increased both in peripheral blood and lower esophageal sphincter in achalasia. Eosinophils decreased in peripheral blood but massively infiltrated in lower esophageal sphincter. CIBERSORT analysis of peripheral blood mononuclear cells RNA sequencing displayed an increased prevalence of CD8+ T cells. 170 dysregulated genes were identified in achalasia, which were enriched in immune cells migration, immune response, etc. Proton pump inhibitor analysis revealed the intersections and gained 7 hub genes in achalasia, which were IL-6, Toll-like receptor 2, IL-1β, tumor necrosis factor, complement C3, and complement C1q A chain.

Conclusion

Patients with achalasia exhibited an imbalance of systematic innate and adaptive immunity, which may play an important role in the development of achalasia.

Adult-onset megacolon with focal hypoganglionosis: A detailed phenotyping and prospective cohort study

BACKGROUND

In this prospective cohort study, we evaluated features of "adult-onset megacolon with focal hypoganglionosis."

METHODS

We assessed the radiologic, endoscopic, and histopathologic phenotyping and treatment outcomes of 29 patients between 2017 and 2020. Data from community controls, consisting of 19,948 adults undergoing health screenings, were analyzed to identify risk factors. Experts reviewed clinical features and pathological specimens according to the London Classification for gastrointestinal neuromuscular pathology.

KEY RESULTS

The median age of the patients with adult-onset megacolon with focal hypoganglionosis at symptom onset was 59 years (range, 32.0-74.9 years), with mean symptom onset only 1 year before diagnosis. All patients had focal stenotic regions with proximal bowel dilatation (mean diameter, 78.8 mm; 95% confidence interval [CI], 72-86). The comparison with community controls showed no obvious risk factors. Ten patients underwent surgery, and all exhibited significant hypoganglionosis: 5.4 myenteric ganglion cells/cm (interquartile range [IQR], 3.7-16.4) in the stenotic regions compared to 278 cells/cm (IQR, 190-338) in the proximal and 95 cells/cm (IQR, 45-213) in the distal colon. Hypoganglionosis was associated with CD3+ T cells along the myenteric plexus. Colectomy was associated with significant symptom improvement compared to medical treatment [change in the Global Bowel Satisfaction score, -5.4 points (surgery) vs. -0.3 points (medical treatment); p < 0.001].

CONCLUSIONS AND INFERENCES

Adult-onset megacolon with focal hypoganglionosis has distinct features characterized by hypoganglionosis due to inflammation. Bowel resection appears to benefit these patients.

Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data

BACKGROUND

Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up.

METHODS

Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment.

RESULTS

The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications.

CONCLUSIONS

Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.

Achalasia Subtype Differences Based on Respiratory Symptoms and Radiographic Findings

Three subtypes of achalasia have been defined using esophageal manometry. Several studies have reported that symptoms are experienced differently among men and women, regardless of subtype. All subtypes could have some impact on the appearance of respiratory symptoms and lung complications due to compression of the trachea or aspiration of undigested food. The aim of this research was to analyze the differences in respiratory symptoms and radiographic presentation of lung pathology depending on the diameter and achalasia types. One or more respiratory symptoms were reported in 48% of 114 patients, and all of them had two or more gastrointestinal symptoms. The symptom score (SS) is statistically significant for the prediction of subtype 1 (area under the curve = 0.318; p < 0.001, cut-off score of 6.5 had 95.2% sensitivity) and subtype 2 (area under the curve = 0.626; p = 0.020, cut-off score of 7.5 had 93.1% sensitivity). The most common type was subtype 2 (50.8%), and although only 14 patients had subtype 3, they had the largest esophageal diameter (mean 5.8 cm). The difference in esophageal diameter was significant between subtype 1 and 3 (p = 0.011), subtype 2 and subtype 3 (p = 0.011). Nine patients (6%) had mega-esophagus (four patients in type 1, three in type 2 and two in type 3). More than half of all patients (51.7%) had at least one parenchymal lung change on CT scan. Recurrent micro-aspirations led to changes in the structure of the airways and lung parenchyma such as ground glass (GGO) and nodular changes (12%) and fibrosis (14.5%), and they had higher esophageal diameters (p < 0.001). Patients with chronic lung CT changes had significantly higher esophageal diameter than with acute changes (p < 0.001). Awareness of the association of achalasia and lung disorders is important in early diagnosis and treatment. More than half (57.5%) of patients with achalasia had some clinical and/or structural pulmonary abnormalities. All three subtypes had similar respiratory symptoms, meaning they cannot be used to predict the subtype of achalasia; on the contrary, SS can predict the first two subtypes. A higher diameter of the esophagus is associated with chronic structural lung changes. Although unexpected, the pathological radiological findings and diameter were significantly different in subtype 3 patients, but those parameters cannot lead us to a specified subtype.

Short-term outcomes after peroral endoscopic myotomy, Heller myotomy, and pneumatic dilation in patients with achalasia: a nationwide analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) are the most common modalities for management of achalasia. Our study aimed to directly compare their short-term outcomes and safety profile in a hospitalized cohort in the United States.

METHODS

The National Readmission Database (2016-2019) was queried using International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify a cohort of inpatient admissions who underwent POEM, LHM, or PD. Baseline demographic variables, resource utilization, periprocedural outcomes, and 30-day readmissions were analyzed. A univariate and multivariate logistic regression model was used to compare odds of readmission with POEM as a reference.

RESULTS

LHM was the most performed procedure (n = 9710) as compared with PD (n = 2453) and POEM (n = 1911). Patients undergoing PD were older with a higher Charlson Comorbidity Index. The 30-day readmission rate was 4.3%, 3.9%, and 12.6% for POEM, LHM, and PD, respectively. Compared with POEM, the adjusted odds of readmission for PD was 2.42 (95% confidence interval, 1.56-3.75). There was no statistically significant difference in odds of readmission for LHM (.91; 95% confidence interval, .62-1.33) compared with POEM. Within the 30-day readmitted population, 13.1% of PD and 3.4% of LHM patients required achalasia-related procedural intervention. The rate of bleeding (4.3%), blood transfusion (2.3%), and mortality were higher (1.1%) in PD as compared with POEM and LHM.

CONCLUSIONS

In the United States, the risk of readmission and resource utilization are higher in patients with achalasia undergoing PD. The outcomes are comparable between POEM and LHM, but there is a significant difference between the utilization of these myotomy procedures.

Myasthenia gravis with achalasia secondary to thymoma: a case report and literature review

Background

Myasthenia gravis is an autoimmune neuromuscular junction disorder characterized by fatigable muscle weakness and autoantibodies. Frequent associations exist between myasthenia gravis and thymic abnormalities, including hyperplasia and thymoma. Several autoimmune illnesses have been identified to be associated with thymoma; however, a few case reports have linked thymoma and achalasia, and the underlying mechanism is unknown.

Case report

A 43-year-old man with thymoma-associated myasthenia gravis presented with dysphagia that was refractory to conventional treatment of myasthenia gravis. This dysphagia was challenging to diagnose even after multiple gastroenterology consults and upper endoscopy. The diagnosis of achalasia type II was established after a comprehensive evaluation, including upper endoscopy, barium swallow, and high-resolution esophageal manometry. The patient underwent elective pneumatic balloon dilatation, which successfully alleviated his dysphagia.

Conclusion

This case confirmed the association between myasthenia gravis secondary to thymoma and achalasia and showed how the diagnosis of achalasia was challenging. Awareness of this association is crucial for early diagnosis and treatment, improving affected patients' quality of life.

Patients with dysphagia: How to supply nutrition through non-tube feeding

OBJECTIVE

Dysphagia has become one of the important factors that cause malnutrition in the whole age group. At present, tube feeding is still the mainstream means to solve the problem of dysphagia. However, tube feeding has physical and mental harm to people, and the ways of non-tube feeding are relatively diversified. The significance of the thickening mechanism described in some articles to solve the problem of dysphagia is not clear.

SETTING AND PARTICIPANTS

All patients with dysphagia worldwide, including oropharyngeal dysphagia (OD) and non-oropharyngeal dysphagia.

METHODS

We searched the literature in Pubmed, Web of Science and Cochrane Library and initially browsed the titles and abstracts. We reviewed the full text of the articles that met our topic, and the language of the article was limited to English.

RESULTS

We found that food thickening to a certain degree (350-1,750 cP) can reduce the complications of choking, aspiration, reflux, and other complications in patients with dysphagia, and reduce the social disorder, anxiety, and other psychological problems caused by catheterization and surgery. Significantly, food science engineers should invite clinicians to intervene in the development of specialty foods from different perspectives such as clinical pathophysiology and fluid mechanics.

CONCLUSION AND IMPLICATIONS

It is necessary to develop special foods for patients with dysphagia, which requires scientists from different disciplines to work together.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Ca2+ signalling in interstitial cells of Cajal contributes to generation and maintenance of tone in mouse and monkey lower esophageal sphincters

KEY POINTS

The lower esophageal sphincter (LES) generates contractile tone preventing reflux of gastric contents into the esophagus. LES smooth muscle cells (SMCs) display depolarized membrane potentials facilitating activation of L-type Ca²⁺ channels. Interstitial cells of Cajal (ICC) express Ca²⁺ -activated Cl^- channels encoded by Ano1 in mouse and monkey LES. Ca²⁺ signaling in ICC activates ANO1 currents in ICC. ICC displayed spontaneous Ca²⁺ transients in mice from multiple firing sites in each cell and no entrainment of Ca²⁺ firing between sites or between cells. Inhibition of ANO1 channels with a specific antagonist caused hyperpolarization of mouse LES and inhibition of tone in monkey and mouse LES muscles. Our data suggest a novel mechanism for LES tone in which Ca²⁺ transient activation of ANO1 channels in ICC generates depolarizing inward currents that conduct to SMCs to activate L-type Ca²⁺ currents, Ca²⁺ entry and contractile tone.

ABSTRACT

The lower esophageal sphincter (LES) generates tone and prevents reflux of gastric contents. LES smooth muscle cells (SMCs) are relatively depolarized, facilitating activation of Ca_v 1.2 channels to sustain contractile tone. We hypothesised that intramuscular interstitial cells of Cajal (ICC-IM), through activation of Ca²⁺ -activated-Cl^- channels (ANO1), set membrane potentials of SMCs favorable for activation of Ca_v 1.2 channels. In some gastrointestinal muscles, ANO1 channels in ICC-IM are activated by Ca²⁺ transients, but no studies have examined Ca²⁺ dynamics in ICC-IM within the LES. Immunohistochemistry and qPCR were used to determine expression of key proteins and genes in ICC-IM and SMCs. These studies revealed that Ano1 and its gene product, ANO1 are expressed in c-Kit⁺ cells (ICC-IM) in mouse and monkey LES clasp muscles. Ca²⁺ signaling was imaged in situ, using mice expressing GCaMP6f specifically in ICC (Kit-KI-GCaMP6f). ICC-IM exhibited spontaneous Ca²⁺ transients from multiple firing sites. Ca²⁺ transients were abolished by CPA or caffeine but were unaffected by tetracaine or nifedipine. Maintenance of Ca²⁺ transients depended on Ca²⁺ influx and store reloading, as Ca²⁺ transient frequency was reduced in Ca²⁺ free solution or by Orai antagonist. Spontaneous tone of LES muscles from mouse and monkey was reduced ∼80% either by Ani9, an ANO1 antagonist or by the Ca_v 1.2 channel antagonist nifedipine. Membrane hyperpolarisation occurred in the presence of Ani9. These data suggest that intracellular Ca²⁺ activates ANO1 channels in ICC-IM in the LES. Coupling of ICC-IM to SMCs drives depolarization, activation of Ca_v 1.2 channels, Ca²⁺ entry and contractile tone. Abstract figure legend Proposed mechanism for generation of contractile tone in the lower esophageal sphincter (LES). Interstitial cells of Cajal (ICC) in the LES generate spontaneous, stochastic Ca²⁺ transients via Ca²⁺ release from the endoplasmic reticulum (ER). The Ca²⁺ transients activate ANO1 Cl- channels causing Cl- efflux (inward current). ANO1 currents have a depolarizing effect on ICC (+++s inside membrane) and this conducts through gap junctions (GJ) to smooth muscle cells (SMCs). Input from thousands of ICC results in depolarized membrane potentials (-40 to -50 mV) which is within the window current range for L-type Ca²⁺ channels. Activation of these channels causes Ca²⁺ influx, activation of contractile elements (CE) and development of tonic contraction. This article is protected by copyright. All rights reserved.

Cross-Sectional Study of Swallowing Phases in Cases of Megaesophagus Caused by Chagas Disease

Background

Chagas disease, caused by the flagellate protozoan Trypanosoma cruzi, is an infectious cause of secondary achalasia and megaesophagus. Moreover, the oral and pharyngeal phases of swallowing may also be affected, which may contribute to dysphagia and increase the possibility of airway aspiration during and/or after swallowing. This cross-sectional study evaluated, with videofluoroscopy, the oral, pharyngeal, and esophageal phases of swallowing in patients with megaesophagus caused by Chagas disease. The hypothesis is that there is impairment of the pharyngeal phase of swallowing that may increase the risk of airway aspiration.

Methods

A total of 29 patients, aged 48 - 73 years (mean: 63.8 ± 5.1 years), with dysphagia, radiological changes in the esophagus, and positive serologic test for Chagas disease, participated in the study. They were submitted to the videofluoroscopic evaluation of oral, pharyngeal, and esophageal phases, swallowing twice 10 mL of liquid and 10 mL of thickened barium boluses.

Results

The most frequent findings were: oral residues and ineffective ejection in the oral phase; residues in vallecula, pharynx, and pyriform sinuses in the pharyngeal phase; abnormal esophageal motility, longer clearance, and longer transit in the esophageal phase. Laryngeal penetration was seen in 28% of the patients. Patients with increased esophageal diameter had more pharyngeal residues than patients without increased esophageal diameter. None of the patients had airway aspiration.

Conclusion

Megaesophagus caused by Chagas disease may affect all phases of swallowing, with an increase in oral and pharyngeal residues which suggest the impairment of oral and pharyngeal efficiency. None of the patients had airway aspiration.

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

Chicago Classification update (version 4.0): Technical review on diagnostic criteria for achalasia

The recommended diagnostic criteria for achalasia have been recently updated by Chicago Classification version 4.0 (CCv4.0), the widely accepted classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). CCv4.0 continued upon prior versions by subtyping achalasia into type I, type II, and type III on HRM. The achalasia subgroup of the CCv4.0 Working Group developed both conclusive and inconclusive statements for the HRM diagnoses of achalasia subtypes. Conclusive achalasia on HRM is defined as an abnormal median integrated relaxation pressure (IRP) in the primary position of wet swallows along with 100% failed peristalsis, with type I achalasia having 100% failed peristalsis without panesophageal pressurization (PEP), type II achalasia with PEP in at least 20% of swallows, and type III achalasia having at least 20% of swallows premature with no appreciable peristalsis. An inconclusive HRM diagnosis of achalasia can arise when there is an integrated relaxation pressure (IRP) that is borderline or at the upper limit of normal in at least one position, there is an abnormal IRP in both positions but evidence of peristalsis with PEP or premature swallows, or there is peristalsis in the secondary position after apparent achalasia in the primary position. In patients with dysphagia and an inconclusive HRM diagnosis of achalasia, supportive testing beyond HRM such as a timed barium esophagram (TBE) for functional lumen imaging probe (FLIP) is recommended. The review recommends a diagnostic algorithm for achalasia, discusses therapeutic options for the disease, and outlines future needs on this topic.

The enteric nervous system in gastrointestinal disease etiology

A highly conserved but convoluted network of neurons and glial cells, the enteric nervous system (ENS), is positioned along the wall of the gut to coordinate digestive processes and gastrointestinal homeostasis. Because ENS components are in charge of the autonomous regulation of gut function, it is inevitable that their dysfunction is central to the pathophysiology and symptom generation of gastrointestinal disease. While for neurodevelopmental disorders such as Hirschsprung, ENS pathogenesis appears to be clear-cut, the role for impaired ENS activity in the etiology of other gastrointestinal disorders is less established and is often deemed secondary to other insults like intestinal inflammation. However, mounting experimental evidence in recent years indicates that gastrointestinal homeostasis hinges on multifaceted connections between the ENS, and other cellular networks such as the intestinal epithelium, the immune system, and the intestinal microbiome. Derangement of these interactions could underlie gastrointestinal disease onset and elicit variable degrees of abnormal gut function, pinpointing, perhaps unexpectedly, the ENS as a diligent participant in idiopathic but also in inflammatory and cancerous diseases of the gut. In this review, we discuss the latest evidence on the role of the ENS in the pathogenesis of enteric neuropathies, disorders of gut-brain interaction, inflammatory bowel diseases, and colorectal cancer.

Achalasia is associated with a higher incidence of depression in outpatients in Germany

Background and aim

Achalasia represents a chronic motility disorder of the esophagus featuring an impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis. By causing dysphagia, regurgitation, aspiration and chest pain, achalasia might tremendously affect life quality of patients. However, the impact of achalasia on the development of mood disorders including depression has largely remained unclear. The aim of this study was to evaluate the incidence of depression in achalasia patients.

Methods

We analyzed a large primary care cohort database in Germany capturing data from 7.49 million patients.

Results

A total of n = 1,057 patients with achalasia diagnosed between January 2005 and December 2018 were matched to a cohort of n = 3,171 patients without achalasia controlling for age, sex, physician, index year, and the Charlson comorbidity index. Interestingly, while the frequency of depression prior to the diagnosis of achalasia was comparable in both groups, new diagnoses of depression were significantly higher within one year after the diagnosis of achalasia compared to the control group, suggesting a direct and previously unrecognized association between achalasia and depression.

Conclusion

Our data suggest that the clinical management of patients with achalasia should include a careful and structured work-up for mood disorders in order to improve long-term quality of life in these patients.