Treatment of Achalasia: Pneumatic Dilation

Forceful dilation of the cardia is the treatment of choice for achalasia. This therapy can be carried out using a homemade system or using commercially available dilators. Pneumatic dilation yields 77% good or excellent results in patients with achalasia, while 8.7% have moderate improvement and 14.4% are not improved. The main complication is perforation, occurring in 2.5%. Perforation can be treated medically with success. In the authors' series of now almost 1000 patients, only one died. Pneumatic dilation is a safe and effective procedure for the treatment of achalasia

A Case of Symptomatic Diffuse Esophageal Spasm During Multiple Rapid Swallowing Test on High-Resolution Manometry

Diffuse esophageal spasm (DES) is an uncommon motility disorder of unknown etiology in which the abnormal motility has been offered as a possible cause for the patient's dysphagia or chest pain. Esophageal manometry is the gold standard for the diagnosis of DES and the diagnostic hallmark is identification of simultaneous contractions in at least 20% of wet swallows, alternating with normal peristalsis. Recently, a new diagnostic technique, high-resolution manometry has been reported to improve the accuracy and detail in describing esophageal function. We report a female patient with intermittent dysphagia and chest pain occurring only when swallowing a large amount of water. On HRM, this patient had esophageal spasms, increased pressurization front velocity attributable to rapid contractile wave front, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES

Deglutitive Inhibition, Latency Between Swallow and Esophageal Contractions and Primary Esophageal Motor Disorders

Swallowing induces an inhibitory wave that is followed by a contractile wave along the esophageal body. Deglutitive inhibition in the skeletal muscle of the esophagus is controlled in the brain stem whilst in the smooth muscle, an intrinsic peripheral control mechanism is critical. The latency between swallow and contractions is determined by the pattern of activation of the inhibitory and excitatory vagal pathways, the regional gradients of inhibitory and excitatory myenteric nerves, and the intrinsic properties of the smooth muscle. A wave of inhibition precedes a swallow-induced peristaltic contraction in the smooth muscle part of the human oesophagus involving both circular and longitudinal muscles in a peristaltic fashion. Deglutitive inhibition is necessary for drinking liquids which requires multiple rapid swallows (MRS). During MRS the esophageal body remains inhibited until the last of the series of swallows and then a peristaltic contraction wave follows. A normal response to MRS requires indemnity of both inhibitory and excitatory mechanisms and esophageal muscle. MRS has recently been used to assess deglutitive inhibition in patients with esophageal motor disorders. Examples with impairment of deglutitive inhibition are achalasia of the LES and diffuse esophageal spasm

Amelioration of intestinal dysmotility and stasis by octreotide early after small-bowel autotransplantation in dogs

Intestinal dysmotility and stasis after intestinal transplantation are considered to promote bacterial overgrowth and translocation. Two prokinetic agents, KW5139 (13-leu-motilin) and the somatostatin analogue octreotide acetate, were studied to determine whether they can ameliorate intestinal dysmotility during the early postoperative period. Motility was recorded by multiple extraluminal strain-gauge transducers in 6 dogs on postoperative days 1, 3, 7, and 14. A barium meal study was performed with a separate group of 8 dogs on postoperative days 3 and 7. The agent KW5139 induced brief, weak contractions in the graft and had little effect on the dilated bowel; however, octreotide induced motor activity that propelled accumulated intestinal contents into the colon and reduced dilation of the transplanted bowel. Octreotide, but not KW5139, ameliorates intestinal dysmotility associated with bowel autotransplantation during the early postoperative period. Short-term administration of octreotide may be useful for the treatment of dysmotility following intestinal transplantation. © 1995, All rights reserved

A Review of Factors Predicting Outcome of Pneumatic Dilation in Patients With Achalasia Cardia

Pneumatic dilation (PD) is an effective treatment for achalasia cardia. Outcome of PD, however, varies among different studies. Recently, some groups started considering laparoscopic myotomy to be competitive to PD in treatment of achalasia considering dreaded complication like perforation following the latter therapeutic approach. Therefore, there is need to predict outcome of PD for achalasia, so that appropriate therapy, both for treatment naïve and for treatment failed patients can be chosen. Apart from age and gender, 2 investigations, namely post-PD manometry and timed barium esophagogram are most often used to predict outcome after PD. Even though there are studies available in the literature with regard to these modalities to predict outcome of PD, these are quite few in number, including small number of patients, primarily because of rarity of the disease. In this article, we review the literature predicting outcome of PD for achalasia

Gender effect on clinical features of achalasia: a prospective study

BACKGROUND: Achalasia is a well-characterized esophageal motor disorder but the rarity of the disease limits performing large studies on its demographic and clinical features. METHODS: Prospectively, 213 achalasia patients (110 men and 103 women) were enrolled in the study. The diagnosis established by clinical, radiographic, and endoscopic as well as manometry criteria. All patients underwent a pre-designed clinical evaluation before and within 6 months after the treatment. RESULTS: Solid dysphagia was the most common clinical symptom in men and women. Chest pain was the only symptom which was significantly different between two groups and was more complained by women than men (70.9% vs. 54.5% P value= 0.03). Although the occurrence of chest pain significantly reduced after treatment in both groups (P < 0.001), it was still higher among women (32% vs. 20.9% P value= 0.04). In both sexes, chest pain did not relate to the symptom duration, LES pressure and type of treatment patients received. Also no significant relation was found between chest pain and other symptoms expressed by men and women before and after treatment. Chest pain was less frequently reported by patients over 56 yrs of age in comparison to those less than 56 yrs (p < 0.05). CONCLUSION: It seems that chest pain is the distinct symptom of achalasia which is affected by sex as well as age and does not relate to the duration of illness, LESP and the type of treatment achalasia patients receive

Erythromycin lacks colon prokinetic effect in children with functional gastrointestinal disorders: a retrospective study

<p>Abstract</p> <p>Background</p> <p>Motilin, a peptide hormone has a direct excitatory effect on circular smooth muscle strips derived from the human colon. Reduced plasma motilin concentration has been reported in adults with chronic constipation. Erythromycin, a non-peptide motilin receptor agonist, induces phase 3 of the migrating motor complex (MMC) in the antro-duodenum and also reduces oro-cecal transit time. A pediatric study has reported an improvement in clinical symptoms of constipation following erythromycin administration, but the effect on colon motility in children has not been formally evaluated. We used colon manometry to study the effect of intravenous erythromycin lactobionate at 1 mg/kg on colon motiltiy in ten children.</p> <p>Methods</p> <p>We selected patients with normal antroduodenal and colon manometry studies that were performed simultaneously. All studies were performed for clinically indicated reasons. We quantified the effect of erythromycin on colon contraction by calculating the area under the curve (AUC).</p> <p>Results</p> <p>The mean (SE of mean) AUC in the colon during the fasting, post-erythromycin and postprandial phases of the study was 2.1 mmHg/sec (0.35), 0.99 mmHg/sec (0.17) and 3.05 mmHg/sec (0.70) respectively. The AUC following erythromycin was significantly less compared to the fasting phase of the study (p < 0.01).</p> <p>Conclusion</p> <p>Erythromycin lacks colon prokinetic effect in children with chronic constipation evaluated by colon manometry.</p

A Single-Lumen Central Venous Catheter for Continuous and Direct Intra-abdominal Pressure Measurement

Background: Abdominal compartment syndrome (ACS) is associated with high morbidity and mortality rates. Therefore, the need for a good diagnostic tool to predict intra-abdominal hypertension (IAH) and progression to ACS is paramount. Bladder pressure (BP) has been used for several years for intra-abdominal pressure (IAP) measurement but has the disadvantage that it is not a continuous measurement. In this study, a single-lumen central venous catheter (CVC) is placed through the abdominal wall into the abdominal cavity to continuously and directly monitor the intra-abdominal pressure (CDIAP). The aim of this study was to evaluate the use of CDIAP to measure BP as a representative of the true IAP. Methods: Both BP and CDIAP were prospectively recorded on a variety of surgical patients admitted to the intensive care unit (ICU) from March 2003 up to December 2004. At the end of the surgical procedure, the CVC was placed through the abdominal wall and connected to a pressure transducer. In addition, the BP was measured through the urine drainage port after clamping the catheter and filling the bladder with 50 ml of 0.9% saline. At least three paired measurements (BP and CDIAP) were performed for at least one day on the ICU in a standardized manner at preset time intervals on each patient. The paired measurements were compared using the Bland-Altman (B-A) method. Data are presented as mean ± standard deviation. Results: Over a period of 22 months (March 2003 until December 2004), 125 paired measurements of both BP and CDIAP were recorded on 25 patients. The mean age was 72.4 ± 6.6 years. Eighteen patients underwent central vascular surgery, and seven patients with peritonitis received laparotomy. The mean CDIAP was 11.4 ± 4.8 (range 2-30) mmHg, and the BP was 12.9 ± 5.3 (range 3-37) mmHg. The mean difference between CDIAP and BP was 1.6 ± 2.7 mmHg. There was an acceptable level of agreement (intraclass correlation 0.82) between IAP measured by BP and IAP measured via CDIAP. Conclusion: Continuous direct intra-abdominal pressure measurement proved that the BP measurement approach of Kron is representative of the IAP. CDIAP measurement is accurate and makes it easier for the nursing staff to be informed of the IAP

Achalasia - An Update

Achalasia is an esophageal motility disorder of unknown cause, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram and confirmed by esophageal manometry. Achalasia cannot be cured. Instead, our goal is to relieve symptoms, improve esophageal emptying and prevent the development of megaesophagus. The most successful therapies are pneumatic dilation and surgical myotomy. The overall success rate of graded pneumatic dilation is 78%, with women and older patients responding best. Laparoscopic myotomy, usually combined with a partial fundoplication, has an overall success rate of 87%. Young patients, especially men, are the best candidates for surgical myotomy. Botulinum toxin injection into the lower esophageal sphincter and smooth muscle relaxants are usually reserved for older patients or those with co-morbid illness. The prognosis for achalasia patients to return to near normal swallowing is good, but the disease is rarely "cured" with a single procedure and intermittent touch-up procedures may be required