The treatment of achalasia patients with esophageal varices: an international study

Background

Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk.

Methods

Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group.

Results

Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 ± 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 non-cirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation.

Conclusion

This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.

Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge

BACKGROUND

Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE.

METHODS

Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance.

KEY RESULTS

Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01).

CONCLUSIONS & INFERENCES

Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.

Ultrasound-assisted fabrication of nanoporous CdS films

A new method for fabricating nanoporous CdS films is reported. It involves exposing the CdS solution with ultrasound waves during the process of dip coating. Indium tin oxide (ITO)-coated glass and plastic (commercial transparency) were used as substrates. In each case three different precursors were used for dip coating. The precursors used were CdCl2 and thiourea in one case and CdS nanoparticles prepared by sonochemical and microwave-assisted methods in the other two cases. X-ray diffraction studies performed on these powders show a phase corresponding to cubic CdS. The Field Emission Scanning Electron Microscopy (FE-SEM) images of the films on plastic showed uniform pores with a diameter of 80 nm for all three methods. Optical absorption measurements indicated a blue shift and multiple peaks in the absorption curve. The FE-SEM observations of the films on an ITO/glass substrate indicated a crystalline film with voids. The UV-vis absorption results indicated a blue shift in the absorption with an absorption edge at 435, 380, and 365 nm for CdS films made by solution growth, sonochemical, and microwave routes, respectively. The magnitude of the absorption is dependent on film thickness, and the observed blue shift in the absorption can be explained on the basis of quantum confinement effects.