Modified barium swallow: clinical and radiographic correlation and relation to feeding recommendations

Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.

Achalasia associated with esophageal diverticula. Prevalence and potential implications

Although esophageal diverticula have been rarely reported in patients with achalasia, their prevalence and the potential implications of the relationship are not well known. We reviewed the medical records and the manometric and radiographic examinations in 120 patients with achalasia to determine the prevalence of esophageal diverticula and to evaluate their importance in this motility disorder. Esophageal diverticula were found in only 6 (5%) of 120 patients, and all were located in the lower half of the esophagus. Sex distribution and the prevalence of dysphagia and regurgitation, which affected all patients with diverticula and 88% of those with achalasia only, were not different significantly. Patients with esophageal diverticula were significantly older (72 vs. 52 years) than those without diverticula. In 5 of 6 patients with diverticula, mean lower esophageal sphincter (LES) pressure was 44.5 mm Hg compared to 39.1 mm Hg in 86 of 114 patients with achalasia only. Treatment by pneumatic dilatation was done in 4 patients with esophageal diverticula and in 105 patients without diverticula. Five esophageal perforations occurred, all in patients without esophageal diverticula.

Percutaneous nephrostomy for treatment of intractable hemorrhagic cystitis

Six patients with severe hemorrhagic cystitis unresponsive to traditional localized therapy were treated with percutaneous nephrostomy for diversion of urine. Bladder hemorrhage ceased in 3 patients, decreased in 2 and was unchanged in 1. In 1 patient with profound thrombocytopenia perirenal hematoma developed as a result of the nephrostomy placement but this complication was self-limited and did not require surgery. Our experience with these 6 patients indicates that nephrostomy diversion is safe and effective in most cases of hemorrhagic cystitis refractory to traditional, nonoperative therapy. Percutaneous urine diversion may obviate the need for surgical urinary diversion in patients who have intractable hemorrhagic cystitis.

Achalasia associated with hiatal hernia: prevalence and potential implications

Although hiatal hernia is reported with a 40-50% frequency in the general population, its occurrence and potential implications in achalasia are less well known. We reviewed the medical records and radiographic examinations of 120 patients with achalasia to assess the prevalence of hiatal hernia and its importance in evaluation and management of this motility disorder. Hiatal hernia was present in only 10 (8.3%) patients. Age, sex distribution, prevalence of dysphagia and regurgitation, and lower esophageal sphincter pressure measured manometrically were not significantly different in patients having hiatal hernia compared to those without hernia. Most patients (88%) underwent pneumatic dilatation and five esophageal perforations occurred, but all in patients without hiatal hernia. In conclusion, hiatal hernia is uncommon in patients with achalasia for reasons not known. Age, sex, symptoms, and results of esophageal manometry were not significantly different in those with hiatal hernia. Finally, the presence of hiatal hernia is not a contraindication to treatment of achalasia by pneumatic dilatation.