European Guideline on Achalasia - UEG and ESNM recommendations

Altres ajuts: These guidelines have been developed and funded within the United European Gastroenterology.Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology, and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A systematic review of the literature was performed and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Recommendations were voted upon using a nominal group technique. These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients

The gastro-oesophageal pressure inversion point revisited

Background: The pressure inversion point (PIP) is defined as the point at which, during stationary pull-through manometry of the oesophago-gastric junction, the polarity of the respiratory-associated pressure variations changes. Traditionally, the PIP is ascribed to transition of the pressure sensor from the abdominal to the thoracic cavity. We used high-resolution manometry to investigate the validity of this concept in six healthy volunteers and six patients with a sliding hiatus hernia. Methods: In the analysis, the position of the PIP was identified. When there was a second, more distal, PIP, its position was also noted. The amplitude of the respiratory-associated pressure variations, defined as the difference between end-expiratory and end-inspiratory pressure, was measured. Results: Double PIPs were found both in healthy controls (23 +/- 8% of time) and in patients (38 +/- 9% of time). Amplitudes of the respiratory-associated pressure variations were significantly higher at the proximal and distal border of the PIP (3.36 +/- 0.2 kPa and 2.29 +/- 0.2 kPa) than in the oesophageal body (0.54 +/- 0.03 kPa, P <0.001) and in the stomach (0.54 +/- 0.03 kPa, P <0.001). We also observed a relationship between the localization of the highest end-expiratory pressure and the position of the PIP. During TLOSRs respiratory variation amplitudes at the proximal and distal border of the PIP decreased to 0.61 +/- 0.02 kPa and 0.29 +/- 0.01 kPa, approximating respiratory pressure variation in oesophagus and stomach. Conclusion: Our findings suggest that the PIP is caused by sliding of the high-pressure zone along pressure sensors rather than by the transition from the thoracic to the abdominal compartment

Double-peaked high-pressure zone at the esophagogastric junction in controls and in patients with a hiatal hernia: A study using high-resolution manometry

The lower esophageal high-pressure zone (HPZ) consists of the intrinsic lower esophageal sphincter (LES) and the diaphragmatic sphincter. In patients with a hiatal hernia these constituents are separated. We performed high-resolution manometry of the esophagogastric HPZ in six controls, six patients with a small hernia, and six patients with a large hernia. Prevalence of a double-peak pressure profile of the HPZ was noted. Pressures and distances between the peaks were assessed. Prevalence of the double-peak profile was similar between patients with a small hernia and controls, but patients with a large hernia showed a higher prevalence with inspiration (

Relationships between air swallowing, intragastric air, belching and gastro-oesophageal reflux

Background: With each swallow a certain amount of air is transported to the stomach. The stomach protects itself against excessive distention by swallowed air through belching (gas reflux). The mechanism of belching (transient lower oesophageal sphincter relaxation) is also one of the mechanisms underlying gastro-oesophageal reflux. Aim: To investigate whether swallowing of air leads to an increase in size of the intragastric air bubble and to gastro-oesophageal reflux. Methods: Multichannel intraluminal impedance measurement was used to quantify the incidence of swallowing of air in 20 healthy volunteers before and after a meal. Radiography was used to measure the size of the intragastric air bubble. Gastro-oesophageal reflux was assessed by concurrent impedance and pH measurement. Results: The rate of air swallowing was correlated to the size of the intragastric air bubble postprandially and to the rate of gaseous gastro-oesophageal reflux. The number of air swallows and the size of the intragastric air bubble did not correlate with the number of liquid acid and non-acid reflux episodes. Conclusions: in healthy subjects, air swallowing promotes belching but does not facilitate acid reflux

Endoscopic management and follow-up of patients with a submucosal esophageal adenocarcinoma

Introduction: The risk of lymph node metastases (LNM) in submucosal esophageal adenocarcinoma (EAC) patients is subject to debate. These patients might be treated endoscopically if the risk of LNM appears to be low. Objective: The objective of this article is to evaluate the outcome of patients who underwent an endoscopic resection (ER) and subsequent endoscopic follow-up for a submucosal EAC. Methods: All patients who underwent ER for submucosal EAC between January 2012 and August 2016 and were subsequently managed with endoscopic follow-up were retrospectively identified. Primary outcome was the number of patients diagnosed with LNM; secondary outcomes included intraluminal recurrences. Results: Thirty-five patients (median age 68 years) were included: 17 low-risk (submucosal invasion 500 microns, and/or G3-G4, and/or LVI, and/or a tumor-positive deep resection margin (R1)) EACs. After a median follow-up of 23 (IQR 15-43) months, in which patients underwent a median of six (IQR 4-8) endoscopies and a median of four (IQR 2-8) endoscopic ultrasound procedures, none of the included patients were diagnosed with LNM. Five (14%) patients developed a local intraluminal recurrence a median of 18 (IQR 11-21) months after baseline ER that were treated endoscopically. Conclusions: In 35 patients with a submucosal EAC, no LNM were found during a median follow-up of 23 months. Endoscopic therapy may be an alternative for surgery in selected patients with a submucosal EAC

The Risk of Inflammatory Bowel Disease-Related Colorectal Carcinoma Is Limited: Results From a Nationwide Nested Case-Control Study

OJECTIVES: The risk for inflammatory bowel disease (IBD)-related colorectal cancer (CRC) remains a matter of debate. Initial reports mainly originate from tertiary referral centers, and conflict with more recent studies. Overall, epidemiology of IBD-related CRC is relevant to strengthen the basis of surveillance guidelines. We performed a nationwide nested case-control study to assess the risk for IBD-related CRC and associated prognostic factors in general hospitals. METHODS: IBD patients diagnosed with CRC between January 1990 and July 2006 in 78 Dutch general hospitals were identified as cases, using a nationwide automated pathology database. Control IBD patients without CRC were randomly selected. Clinical data were collected from detailed chart review. Poisson regression analysis was used for univariable and multivariable analyses. RESULTS: A total of 173 cases were identified through pathology and chart review and compared with 393 controls. The incidence rate of IBD-related CRC was 0.04%. Risk factors for IBD-related CRC were older age, concomitant primary sclerosing cholangitis (PSC, relative ratio (RR) per year duration 1.05; 95% confidence interval (CI) 1.01-1.10), pseudopolyps (RR 1.92; 95% CI 1.28-2.88), and duration of IBD (RR per year 1.04; 95% CI 1.02-1.05). Using immunosuppressive therapy (odds ratio (OR) 0.3; 95% CI 0.16-0.56, P < 0.001) or anti-tumor necrosis factor (TNF) (OR 0.09; 95% CI 0.01-0.68, P < 0.02) was protective. CONCLUSIONS: We found a limited risk for developing IBD-related CRC in The Netherlands. Age, duration of PSC and IBD, concomitant pseudopolyps, and use immunosuppressives or anti-TNF were strong prognostic factors in general hospitals