Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations

Modern insights into the pathophysiology and treatment of pseudoachalasia

BACKGROUND

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

METHODS

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

RESULTS

Etiology, diagnosis, and treatment were reviewed.

CONCLUSIONS

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

Pseudoachalasia: a diagnostic challenge. When to consider and how to manage?

Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.

An Involuntary and Unexpected Treatment of Nutcracker Esophagus

A 76-year-old woman complained of painful dysphagia and loss of weight. Esophagoscopy results were negative, whereas computed tomography (CT) disclosed a 25-mm mediastinal tumor without a connection to the esophagus. A diagnosis of nutcracker esophagus was made on high-resolution esophageal manometry. Peroral endoscopic esophageal myotomy failed to improve the symptoms. Right video thoracoscopy allowed resection of the tumor, which looked like a neurogenic tumor of the posterior mediastinum that developed from the right vagus nerve. The patient's dysphagia dramatically improved postoperatively. Because the pathologic examination disclosed a benign solitary fibrous tumor of the pleura, we hypothesize that the motility disorder would have been resolved by the unilateral vagotomy.

Pseudoachalasia: a diagnostic challenge

Here, we present a case of a 78-year-old man that underwent gastrointestinal endoscopy because of one- month history of dysphagia to liquids and solid foods with accompanying weight loss. On endoscopy, there was distal esophageal stenosis. Multiple biopsies were obtained. Histologic examination of the samples revealed normal tissue. The stenosis was treated by dilatation and abdomino pelvic computed tomography scanning was performed to search for an underlying malignant lesion that showed a mass adjacent to distal esophagus. We did endosonography- guided fine needle aspiration of the mass. It was a squamous cell carcinoma (SCC). Malignancy is a challenging diagnosis in patients with dysphagia and near normal endoscopy. To our knowledge, there are a few reports of SCC to cause it.

2011 update on esophageal achalasia

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years. First, the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes. The most favorable outcome is predicted for patients receiving treatment for type II achalasia (achalasia with compression). Patients with typeI(classic achalasia) and type III achalasia (spastic achalasia) experience a less favorable outcome. Second, the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD). Although the follow-up period was not long enough to reach a convincing conclusion, it merits the continued use of PD as a generally available technique in gastroenterology. Third, the novel endoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and cautious evaluation. Despite all this good news, the bottom line is a real breakthrough from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.

Endoscope-guided pneumatic dilation for treatment of esophageal achalasia

Pneumatic dilation (PD) is considered to be the first line nonsurgical therapy for achalasia. The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force. The endoscope-guided procedure is done without fluoroscopic control. Clinicians usually use a low-compliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia. It has the advantage of determining mucosal injury during the dilation process, so that a repeat endoscopy is not needed to assess the mucosal tearing. Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities. Although the results may be promising, long-term follow-up is required in the near future.

Clinical remission in endoscope-guided pneumatic dilation for the treatment of esophageal achalasia: 7-year follow-up results of a prospective investigation

BACKGROUND AND AIMS

Prospective, long-term reports and predictors of outcome of endoscope-guided pneumatic dilation are lacking in the literature. The aim of this prospective 7-year follow-up study is to report the efficacy of endoscope-guided pneumatic dilation and determine the possible confounding factors related to remission.

METHODS

Between January 1998 and June 2004, 32 patients were enrolled. Each patient was treated with endoscope-guided pneumatic dilation and followed-up at regular intervals for a median of 4.5 years. Remission was determined with the use of a structured interview and a previously described symptom score. Cumulative remission rate was analyzed by using the Kaplan-Meier method with assessment of symptom scores between grades before and after PD at 6 weeks, 6 months, 1 year, and then every year after. Possible confounding factors related to the remissions were analyzed by Cox's proportional hazard model.

RESULTS

Complete follow-up until August 2007 was obtained in 100% of all patients. Cumulative remissions were 1 year (86.7%), 2 years (86.7%), 3 years (80.0%), 4 years (76.5%), 5 years (72.9%), 6 years (61.7%), and 7 years (61.7%), respectively. Age is a relevant confounding factor to the remissions showing a worse outcome for those under 45 (p = 0.046). One esophageal perforation occurred (3.3%).

CONCLUSIONS

Endoscope-guided PD itself is safe and modestly effective for up to 7 years investigations in current study. Older patients (>45 years) have favorable overall clinical remissions.

The role of barium esophagogram measurements in assessing achalasia patients after endoscope-guided pneumatic dilation

Only a few studies have been performed comparing subjective symptom improvements with objective improvement in esophageal emptying after pneumatic dilation (PD), and discrepancy existed. We evaluated whether esophagogram measurements adds to the traditional subjective symptoms scores in assessing achalasia patients after PD. We enrolled 32 new patients with achalasia who received endoscope-guided PD treatment between January 1998 and June 2004. Postdilation investigations were performed by using esophageal emptying on esophagogram prospectively in a blinded manner, along with symptom scores before and after PD at the initial investigation, 6 weeks later, and every 1 year thereafter. Our results showed that seven patients who noted complete relief showed less than 50% improvement in barium column height and esophageal diameter. There was no linear correlation between the degree of patient symptom improvement and esophageal emptying measured by esophagogram (r = 0.181, P = 0.322). A trend of association existed in the relationship between clinical remissions and initial post-PD esophageal emptying improvement (P = 0.067). In summary, the association between the post-PD symptom score improvement and degrees of esophageal emptying may be hampered by the small sample size in the current study. An additional objective parameter like esophagogram to the subjective symptom scores may be more optimal in assessing clinical remissions.

Endoscope-guided pneumatic dilatation of esophageal achalasia without fluoroscopy is another safe and effective treatment option: a report of Taiwan

This study reports the usefulness and safety of endoscope-guided pneumatic dilatation (PD) technique without using fluoroscopy. From January 1998 to June 2004, a total of 33 patients with achalasia, including 20 males and 13 females, received PD in our unit. The mean age was 48.5+/-17.5 years (range: [corrected] 18 to 93 y). All patients underwent endoscopic-guided PD by using a 3.0 cm [corrected] diameter "Regiflex" balloon dilator (Microvasive, Watertown, MA). The results of PD were recorded and evaluated by symptom scores based on the frequency of attack of 3 major symptoms: dysphagia, regurgitation, and chest pain, both before, and then 6 weeks, 6 months, 1 year after PD was performed. Thirty-three patients were treated, excellent results in 27, good results in 3, and failure in 3 (1 requiring surgical treatment later). Overall, we demonstrated that the technique is effective and safe option for achalasia treatment.