Agreement between upper endoscopy and esophagography in the diagnosis of megaesophagus in Chagas disease

Abstract INTRODUCTION The diagnosis and classification of megaesophagus can be challenging in patients with Chagas disease. The present study aimed to evaluate the agreement between upper endoscopies and esophagographies for the diagnosis and classification of megaesophagus in Chagas disease. METHODS: A cross-sectional study of 50 patients with Chagas disease with upper digestive symptoms was undertaken. Esophagography and upper endoscopy exams were performed to compare diagnoses. Statistical analysis included sensitivity and specificity used to evaluate the diagnostic accuracy of upper endoscopies, and measures of agreement: linearly weighted Kappa (κw) and Cohen`s classical Kappa (κ) coefficients with 95% confidence intervals (95% CI). RESULTS: Twenty-three patients (46%) were diagnosed with megaesophagus by esophagography. The upper endoscopy sensitivity and specificity for megaesophagus diagnosis were 100% and 33.3%, respectively. Regarding megaesophagus classifications, there was a substantial agreement between the two exams (κw = 0.622; 95% CI: 0.498 to 0.746). Within megaesophagus groups, agreement for group I was slight (κ = 0.096; 95% CI: 0.000 to 0.403); for group II, substantial (κ = 0.703; 95% CI: 0.456 to 0.950); and for groups III and IV, inconclusive (κ = 0.457; 95% CI: 0.000 to 0.967; κ = 0.540; 95% CI: 0.035 to 1.000, respectively). CONCLUSIONS Upper endoscopy has a high sensitivity, but a low specificity to diagnose megaesophagus. Agreement between the two exams varies depending on the megaesophagus grade. Thus, upper endoscopy can be used in the diagnostic workup of a possible Chagas disease megaesophagus, but all identified cases should undergo esophagography.

Achalasia Is Associated With eNOS4a4a, iNOS22GA, and nNOS29TT Genotypes: A Case-control Study

BACKGROUND/AIMS: Achalasia is known to result from degeneration of inhibitory neurons, which are mostly nitrinergic. Characteristic features of achalasia include incomplete lower esophageal sphincter (LES) relaxation and esophageal aperistalsis. Nitric oxide (NO), produced by NO synthase (NOS), plays an important role in peristalsis and LES relaxation. Therefore, we evaluated genetic polymorphisms of NOS gene isoforms (endothelial NOS [eNOS], inducible NOS [iNOS], and neuronal NOS [nNOS]) in patients with achalasia and healthy subjects (HS). METHODS: Consecutive patients with achalasia (diagnosed using esophageal manometry) and HS were genotyped for 27-base pair (bp) eNOS variable number of tandem repeats (VNTR), iNOS22G/A (rs1060826), nNOS C/T (rs2682826) polymorphisms by polymerase chain reaction (PCR) and PCR-restriction fragment length polymorphism (RFLP), respectively. RESULTS: Among 183 patients (118 [64.5%] male, age 39.5 +/- 13.0 years) with achalasia and 366 HS (254 [69.4%] male, age 40.8 +/- 11.0 years), eNOS4a4a genotype of 27-bp VNTR was more common among achalasia than HS (20 [10.9%] vs 13 [3.6%]; P < 0.001; OR, 3.72; 95% CI, 1.8-7.7). Patients with achalasia had iNOS22GA genotypes more often than HS (95 [51.9%] vs 93 [25.4%]; P < 0.001; OR, 3.0; 95% CI, 2.1-4.4). Frequency of genotypes GA + AA was higher in patients than HS (97 [53%] vs 107 [29.2%]; P < 0.001; OR, 2.7; 95% CI, 1.8-3.9). Also, nNOS29TT variant genotype in rs2682826 was more common among patients compared to HS (14 [7.7%] vs 6 [1.6%]; P < 0.001; OR, 5.91; 95% CI, 2.2-15.8). CONCLUSIONS: Achalasia is associated with eNOS4a4a, iNOS22GA, and nNOS29TT genotypes. This may suggest that polymorphisms of eNOS, iNOS, and nNOS genes are risk factors for achalasia.

Utilizing Intrabolus Pressure and Esophagogastric Junction Pressure to Predict Transit in Patients With Dysphagia

BACKGROUND/AIMS: High-resolution manometry (HRM), with a greatly increased number of recording sites and decreased spacing between sites, allows evaluation of the dynamic simultaneous relationship between intrabolus pressure (IBP) and esophagogastric junction (EGJ) relaxation pressure. We hypothesized that bolus transit may occur when IBP overcomes integrated relaxation pressure (IRP) and analyzed the relationships between peristalsis pattern and the discrepancy between IBP and IRP in patients with dysphagia. METHODS: Twenty-two dysphagia patients with normal EGJ relaxation were examined with a 36-channel HRM assembly. Each of the 10 examinations was performed with 20 and 30 mmHg pressure topography isobaric contours, and findings were categorized based on the Chicago classification. We analyzed the relationships between peristalsis pattern and the discrepancy between IBP and IRP. RESULTS: Twenty-two patients were classified by the Chicago classification: 1 patient with normal EGJ relaxation and normal peristalsis, 8 patients with intermittent hypotensive peristalsis and 13 patients with frequent hypotensive peristalsis. A total of 220 individual swallows were analyzed. There were no statistically significant relationships between peristalsis pattern and the discrepancy between IBP and IRP on the 20 or 30 mmHg isobaric contours. CONCLUSIONS: Peristalsis pattern was not associated with bolus transit in patients with dysphagia. However, further controlled studies are needed to evaluate the relationship between bolus transit and peristalsis pattern using HRM with impedance.

Achalasia Cardia Subtyping by High-Resolution Manometry Predicts the Therapeutic Outcome of Pneumatic Balloon Dilatation

BACKGROUND/AIMS: High-resolution manometry (HRM) with pressure topography is used to subtype achalasia cardia, which has therapeutic implications. The aim of this study was to compare the clinical characteristics, manometric variables and treatment outcomes among the achalasia subtypes based on the HRM findings. METHODS: The patients who underwent HRM at the Asian Institute of Gastroenterology, Hyderabad between January 2008 and January 2009 were enrolled. The patients with achalasia were categorized into 3 subtypes: type I - achalasia with minimum esophageal pressurization, type II - achalasia with esophageal compression and type III - achalasia with spasm. The clinical and manometric variables and treatment outcomes were compared. RESULTS: Eighty-nine out of the 900 patients who underwent HRM were diagnosed as achalasia cardia. Fifty-one patients with a minimum follow-up period of 6 months were included. Types I and II achalasia were diagnosed in 24 patients each and 3 patients were diagnosed as type III achalasia. Dysphagia and regurgitation were the main presenting symptoms in patients with types I and II achalasia. Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II. Most patients underwent pneumatic dilatation (type I, 22/24; type II, 20/24; type III, 3/3). Patients with type II had the best response to pneumatic dilatation (18/20, 90.0%) compared to types I (14/22, 63.3%) and III (1/3, 33.3%). CONCLUSIONS: The type II achalasia cardia showed the best response to pneumatic dilatation.

Endoscopic Treatment of Primary Esophageal Motility Disorders / 대한소화기내시경학회지

Treatment of primary esophageal motility disorders, particularly achalasia, has developed enormously. The proven treatments for these patients include mostly endoscopic methods. Currently, pneumatic dilatation and laparoscopic myotomy with partial fundoplication are both useful for treating achalasia. A young man with high lower esophageal sphincter pressure might be best indicated for a laparoscopic myotomy with fundoplication, whereas an older patient with a high risk for surgery or vigorous achalasia may for a candidate for an endoscopic botulinum toxin injection. Pneumatic balloon dilatation is the choice of treatment for other cases of achalasia. The best treatment option for a nonachalasia spastic motor disorder of the esophagus may be endoscopic injection of botulinum toxin. In the future, endoscopic injection of neuronal stem cells could be the best treatment option for achalasia.

Acalasia y dilatación con balón neumático: Experiencia en pacientes pediátricos

La acalasia es un trastorno motor primario esofágico, caracterizado por pérdida de la peristalsis y falla en la relajación del esfínter esofágico inferior (EEI) en respuesta a la deglución. El tratamiento está dirigido a conseguir la disrupción de las fibras circulares del EEI bien por dilatación neumática o miotomía. El objetivo del estudio fue reportar la experiencia con dilatación neumática para el tratamiento de la acalasia en niños en la Unidad de Gastroenterología y Nutrición Pediátrica del Hospital Miguel Pérez Carreño (Caracas, Venezuela), en el período comprendido de enero 2000 a diciembre 2007. Pacientes y método: Se estudiaron de forma prospectiva 8 pacientes con diagnóstico radiológico, manométrico y endoscópico de acalasia, quienes fueron sometidos a dilatación neumática y posteriormente se les realizó seguimiento clínico y manométrico para objetivar su respuesta al tratamiento. Se calculó un score de severidad para los síntomas digestivos, según lo propuesto por Kim, et al. antes del procedimiento y posteriormente al mes y los 6 meses, se calculó el porcentaje de mejoría con respecto al inicial. Resultados: La media de edad fue de 8,3 años. No hubo predominio de género. El 100% presentó disfagia y regurgitaciones y 87,5% desnutrición y tos crónica. Los procedimientos se llevaron a cabo sin complicaciones. 1 paciente (12,5%) requirió una segunda sesión de dilatación por persistir con clínica. La evolución fue satisfactoria, con reducción notable de los síntomas al mes (87,5%) y a 6 meses (100%). Conclusiones: consideramos que la dilatación neumática es una terapia costo-efectiva, con buena respuesta a corto y mediano plazo, baja morbilidad y continúa siendo la terapia de primera elección en el tratamiento de los pacientes pediátricos con acalasia.

Achalasia of the cardia is a disorder of esophageal motility characterized by loss of peristalsis and failure of relaxation of the lower esophageal sphincter (LES) at swallowing. Treatment is directed toward symptomatic relief of the disorder by disrupting the circular muscle fibers of the lower esophageal sphincter . This can be achieved with surgical cardiomyotomy or balloon dilation. The aim of this study was to report the experience with pneumatic ballon dilation for treatment of achalasia in children in Pediatric Gastroenterology and nutrition Unit of Miguel Perez Carreño Hospital (Caracas, Venezuela), in the period between January, 2000 on December, 2007. Patients and method: 8 patients with radiological, manometric and endoscopic diagnosis of achalasia were studied prospectively, they were submitted to pneumatic dilation and later to a clinical and manometric follow-up with the objective of register their response to the treatment. A score of severity was calculated for the digestive symptoms, according to the proposed for Kim, et al. Before the procedure and later a month and the 6 months, the percentage of improvement was calculated with regard to initial one. Results: The average of age was of 8,3 years. There was no predominance of genre. 100 % of patients presented dysphagia and regurgitation and 87,5 % malnutrition and chronic cough. The procedures werw ended without complications. 1 patient (12,5%) needed a second session of dilation for persisting with clinic. The evolution was satisfactory, with notable reduction of the symptoms to one month (87,5 %) and to 6 months (100 %). Conclusions: we think that the pneumatic expansion is a therapy cost effective, with good response to short and medium term, low morbidity and continues being the first choice therapy in the treatment of the paediatric patients with acalasia.

Esophageal motility disorder suspected during endoscopy / 대한내과학회지

No abstract available.

A Study of Esophageal Acidity and Motility Change after a Gastrectomy for Stomach Cancer

PUPOSE: Some patients develop gastroesophageal reflux disease (GERD) after a gastrectomy for stomach cancer. Therefore, we conducted this research to gain an understanding of esophageal acidity and motility change. MATERIALS AND METHODS: From July 2002 to March 2004, the cases of 15 randomized patients with stomach cancer who underwent a radical subtotal gastrectomy (RSG) with Billroth I(B-I) reconstruction (n=12) or a radical total gastrectomy (RTG) with Roux-en-Y (R-Y) gastroenterostomy (n=3) were analyzed. We investigated the clinical values of the ambulatory 24-hour pH monitoring and esophageal manometry in these patients, just before discharge from the hospital after an operation. RESULTS: GERD was present in three patients (20%). Compared with two reconstructive procedures, 3 of the 12 patients in the RSG with B-I group had GERD; however, none of RTG with R-Y group had GERD. Compared with pathologic stage, 2 of 9 patients in stage I, 1 of 2 patients in stage II, none of 3 patients in stage III, and none of 1 patient in stage IV had GERD. Esophageal manometry was performed in 10 patients. Nonspecific esophageal motility disorder (NEMD) was present in 7 patients. CONCLUSION: Some patients had GERD as a complication following a gastrectomy for stomach cancer. We suspect that the postoperative esophageal symptom is due to not only bile reflux but also gastroesophageal acid reflux. Therefore, careful observation is recommended for the detection of GERD.

Esophageal Manometric Findings of 1,746 Patients with Esophageal Symptoms / 대한소화관운동학회지

BACKGROUND/AIMS: To evaluate the prevalence, relationship between symptoms and esophageal motility disorders, and the factors that could affect in esophageal motility, we performed a manometric study and analyzed the results in a large number of patients with esophageal symptoms. METHODS: Records from 1746 patients referred to our manometric laboratory for evaluation of esophageal symptoms between September 1994 and September 2002 were enrolled. We used low compliance pneumohydraulic capillary infusion system to perform esophageal manometry. RESULTS: Among patients with abnormal esophageal motility, 390 cases of nonspecific esophageal motility disorder, 20 cases of nutcracker esophagus, 11 cases of achalasia, 4 cases of hypertensive lower esophageal sphincter, and 4 cases of diffuse esophageal spasm were present. The symptoms of 1746 patients were oropharyngeal dysphagia, esophageal dysphagia, non-cardiac chest pain or chest discomfort, substernal soreness or heartburn, regurgitation, and lump sensation. In multivariate analysis, age (OR=1.95; p=0.007) was an independent factor affecting esophageal motility. CONCLUSIONS: There are esophageal motility disorders in 24.6% of patients with esophageal symptoms, and various symptoms are present in them. The factor associated with the abnormal findings of esophageal manometry is age.

The Prevalence of Gastroesophageal Reflux Disease in Patients with Nonspecific Esophageal Motility Disorder / 대한소화관운동학회지

BACKGROUND/AIMS: The nonspecific esophageal motility disorder (NEMD) has been reported to be related to gastroesophageal reflux disease (GERD) in some cases. However, the pathophysiologic mechanism of NEMD has not been estabilished. The aim of this study was to assess the prevalence of esophagitis and gastric acid reflux following abnormal contractions in patients with NEMD. METHODS: 122 NEMD patients were enrolled (76 male and 46 female) and their endoscopic findings and 24 hour esophageal pH data were compared with 24 healthy subjects. The abnormal contractions were classified as 1) non-transmitted contraction, 2) low amplitude contraction, 3) non-transmitted and low amplitude contraction, and 4) others. RESULTS: Among the 122 patients with NEMD, 62 patients (50.8%) had GERD, 53 patients (43.4%) had endoscopic reflux esophagitis, and 41 patients (33.6%) had both. Acid exposed time studied by 24 hour pH monitoring was more increased in NEMD patients than in healthy controls (7.48 +/- 10.68 vs 1.42 +/- 1.17), but there were no differences among abnormal contraction patterns. Moderate to severe reflux esophagitis were frequently seen in patients with combined abnormal contractions as the results of endoscopic findings. Pre-existing factors for the gastric acid reflux in NEMD patients were male and esophageal hiatal hernia. CONCLUSIONS: Large numbers of NEMD patients were found to have concurrent GERD in our study. However, the esophageal peristaltic dysfunction was more closely related to the severity of esophagitis rather than to the amount of refluexed gastric acid itself.

Esophageal Motility and Reflux Diseases in Patients with Noncardiac Chest Pain / 대한소화관운동학회지

BACKGROUND/AIMS: Some patients complaining chest pain have normal coronary angiograms. In these cases of noncardiac chest pain, esophageal disease might be a reasonable explanation. However, causal relationship between esophageal motility or reflux disease and chest pain may be difficult to be proven. Therefore, we performed this study to evaluate the esophageal abnormality as a potential cause of noncardiac chest pain. METHODS: We underwent esophagogastroduodenoscopy, esophageal mancenetry and 24 hour esophageal pH monitoring in 58 patients with chest pain and normal coronary arteriogram or negative thallium study. RESULTS: Of 58 patients, 17 patients (29.3%) had abnormal esophageal manometry test. There were 6 cases of nonspecific esophageal motility disorder, 5 cases of hypertensive lower esophageal sphincter, 5 cases of diffuse esophageal spasm and 1 case of nutcracker esophagus. In 56 patients with 24 hour pH monitoring, 13 patients had positive DeMeester score and 29 patients experienced chest pain during the test period. 11 patients (18.9%) had both positive DeMeester score and chest pain. Mean symptom index of these patients was 70.0% (range 40-100%). CONCLUSIONS: Esophageal motility disorders and gastroesophegeal reflux diseases were frequantly found in patients with noncardiac chest pain. Much efforts should be made to find esophageal cause in patients with noncardiac chest pain.

Gastroesophageal Reflux and Esophageal Motility Disorder in Patients with Liver Cirrhosis / 대한소화관운동학회지

BACKGROUNDS/AIM: Patients with liver cinhosis suffer from indigestion, abdominal discamfort, or dysphagia, but causes of these symptoms are unknown. Ascites, esophageal varix, fiequency of variceal ligatian, and poor residual liver function are considered as the causes, despite no consistent result. There has been no report about pogestaone known to decrease the pressure of lower esophageal sphincter at pregnancy in cirrhotic patients. We evaluated the factors affecting gastroesaphageal reflux and esophageal matility disarder in patients with cirrhosis. SUBJECTS AND METHODS: Between May 1997 and September 1998, 24 cinhotic patients(18 men and 6 women, mean age 51.8+/-9.7yr) were enrolloed. All patients were subjected to abdominal ultrasonography, esophageal manometry, ambulatary 24hr esophageal pH monitoring, esophagogastroduodenoscopy, and serum levels of esttogen and pogesterone. After ascites was conttolled, these studies were performed again in 5 patients. RESULTS: 1) Thae was no correlation between amount of ascites and esophageal motility disceder, gastroesophageal reflux. But, after ascites was controlled, lower esaphageal pressure tended to increase. 2) There was no correlation between grade of esophageal varix and esophageal manometric abnormalities. 3) There was inverse carrelation between frequency of esophageal variceal ligation and upper esophageal pessure. 4) There was invase correlation between lower esophageal pressure and serum level of esttogen, progesterone. 5) There was no correlation between severity of liver cirrhosis, age and esophageal motility disceders, pstroesophageal reflux. CONCLUSIONS: Factors affecting esophageal motility disorders in cirrhatic patients are ammout of ascites, frequency of esophageal variceal ligations, and serum levels of estrogen and progesterrone.

Importance of Psychological Factors and Organic Factors in Globus Pharyngeus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Recently, researchers have come to believe that gastroesophageal reflux (GER) and esophageal motility disorders are the most important etiologic factors causing globus pharyngeus. On the other hand, psychological factors such as somatization or depression are regarded as relatively less important etiologic factors. In an attempt to verify this current belief, the authors performed a prospective study in patients who complained of globus sensation in the throat. MATERIALS AND METHODS: Among 62 adult patients with globus symptoms, 33 patients underwent 24-hour esophageal ambulatory pH-monitoring: 46 patients underwent esophageal manometry: 26 patients underwent Minnesota multiphasic personality inventory (MMPI): and 25 patients underwent Becks depression index (BDI) test. RESULTS: GER was diagnosed in 21.2% of the tested patients and non-specific esophageal motility disorder was found in 4.3%. MMPI showed abnormalities in 57.7% of the tested patients, and BDI showed a high index of depression in 96% of the tested patients. CONCLUSIONS: In contrast to the current belief, GER and esophageal motility disorder should be regarded as just one of the possible etiologic factors, and psychological factors should not be ignored in the evaluation of a patient with globus pharyngeus.

Surgical Experience of Diffuse Esophageal Spasm: A report of 2 cases / 대한흉부외과학회지

Diffuse esophageal spasm (DES) is a rare disease seen in 4% of all patients studied in an esophageal motility laboratory, and its diagnosis and surgical management is still controversial. Recently, we treated two patients by extended esophageal myotomy for diffuse esophageal spasm which was diagnosed by the clinical symptoms of patients, esophagoscopy, esophagography, and esophageal manometry. The successful result of treatments was proved with subsidence of previous clinical symptoms (dysphagia and chest pain), postoperative esophagography and esophageal manometry. We present the results together with the review of literatures.

A Case of Nutcracker Esophagus Associated with Gastroesophageal Reflux: Normalization of Manometry Finding after Omeprazole Therapy / 대한소화관운동학회지

Gastroesophageal reflux disease (GERD) is thought to be caused by an incompetent lower esophageal sphincter, either because of a chronic hypotonia or an increased frequency of transient lower esophageal sphincter relaxation. Thus, it seems paradoxical under nutcracker esophagus to consider gastroesophageal reflux as a possible diagnosis, particularly in the patient presenting with chest pain. Current therapy in nutcracker esophagus is aimed at reducing the high amplitude peristaltic contractions characteristic of this disorder. Treatment directed at reducing contraction can decrease lower esophageal sphincter pressure and may exacerbate gastroesophageal reflux. It is not easy to treat a case of nutcracker esophagus associated with GERD. We report a 38-year-old male with nutcracker esophagus associated with GERD who lost the diagnostic features of nutcracker esophagus after 6 week of antireflux therapy.

Clinical Evaluation of Radionuclide Esophageal Transit Study in Patients with Nonspecific Esophageal Motility Disorder / 대한내과학회지

OBJECTIVES: Nonspecific esophageal motility disorder(NEMD) is a vague category used to group poorly defined contraction abnormalities. We evaluated the clinical characteristics and esophageal transit time (ETT) in patients with NEMD. METHODS: Total 205 patients with NEMD were compared with 20healthy controls and 99patients with other motility disorders of the esophagus. Esophageal manometry was performed with a lowcompliance pneumohydraulic capillary infusion system and esophageal scintigraphy was performed for the liquid and solid swallow after manometric study. RESULTS: 1) Among the total 258abnormal contractions in 205patients with NEMD, non-transmitted contractions were 125(45.5%), low amplitude 110(42.6%), triple peaked 3(1.2%), prolonged duration contractions 12(4.7%) and isolated incomplete LES relaxation 8(3.1%). 2) NEMD patients have significantly delayed ETT similar to that seen in patients with diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter for liquid, and diffuse esophageal spasm, hypertensive lower esophageal sphincter for solid. 3) ETT for liquid and solid according to abnormal contractions were 39.0 and 55.6seconds in non-transmitted, 38.3, 68.4 seconds in low amplitude, 17.0, 30.0 seconds in triple peaked, 29.4, 25.8 seconds in prolonged-duration contractions and 13.7, 15.5 seconds in isolated incomplete LES relaxation, respectively. CONCLUSION: Patients with NEMD have significantly delayed ETT for liquid and solid compare to normal control. The main abnormal contractions of NEMD were non-transmitted and low amplitude contractions. And low amplitude contractions were the main cause of delayed solid transit in patients with NEMD(p<0.01).