Esofagitis eosinofílica y acalasia esofágica / Eosinophilic esophagitis and esophageal acalasia

Introducción: La esofagitis eosinofílica es una enfermedad emergente, caracterizada por infiltración del esófago por leucocitos eosinófilos. Sus principales síntomas son la disfagia y las frecuentes impactaciones de alimento en el esófago. Actualmente existen evidencias científicas que reconocen la enfermedad como causa posible de evolución no favorable en pacientes después de miotomía de Héller. Objetivo: Describir las evidencias biomoleculares que asocian la esofagitis eosinofílica y la acalasia esofágica. Métodos: Se realizó una revisión sistemática y crítica de las evidencias sobre los mecanismos biomoleculares asociados a la esofagitis eosinofílica y la acalasia esofágica. Se consultaron artículos publicados entre 2015 y 2020 e indexados en las bases de datos PubMed, SciELO, LILACS y Scopus. Análisis e integración de la información: Se discute sobre cuestiones medulares que han sido publicadas recientemente respecto al tema en cuestión. ¿Pueden coexistir la esofagitis eosinofílica y la acalasia esofágica? ¿Influye la esofagitis eosinofílica en el resultado del tratamiento de la acalasia esofágica? ¿Qué investigaciones serían necesarias para establecer la relación entre las dos enfermedades? Conclusiones: Los mecanismos celulares y biomoleculares desencadenados por la infiltración eosinofílica contextualizan la diferencia etiológica y fisiopatológica de la esofagitis eosinofílica y la acalasia esofágica, lo cual sustenta la evolución desfavorable posmiotomía de los pacientes y motiva la realización de estudios prospectivos y controlados con el fin de ofrecer una mejor calidad de vida(AU)

Introduction: Eosinophilic esophagitis is an emerging disease characterized by infiltration of the esophagus by eosinophilic leukocytes. Its main symptoms are dysphagia and frequent food impaction in the esophagus. Scientific evidence is now available that recognizes the disease as the possible cause of unfavorable evolution in patients undergoing Heller myotomy. Objective: Describe the biomolecular evidence associating eosinophilic esophagitis to esophageal achalasia. Methods: A systematic critical review was conducted of the evidence about biomolecular mechanisms associated to eosinophilic esophagitis and esophageal achalasia. The articles consulted were published in the databases PubMed, SciELO, LILACS and Scopus from 2015 to 2020. Data analysis and integration: A discussion is provided about crucial questions published recently concerning the study topic: Can eosinophilic esophagitis and esophageal achalasia coexist? Does eosinophilic esophagitis influence the result of esophageal achalasia treatment? What studies are required to establish the relationship between the two conditions? Conclusions: The cellular and biomolecular mechanisms triggered by eosonophilic infiltration contextualize the etiological and pathophysiological difference between eosinophilic esophagitis and esophageal achalasia. This explains the unfavorable post-myotomy evolution of patients and encourages the conduct of prospective controlled studies aimed at enhancing quality of life(AU)

Manometría de alta resolución en pacientes con trastornos motores esofágicos / High resolution manometry in patients with esophageal motor disorders

Introducción: La manometría de alta resolución es la prueba de referencia para el estudio de los trastornos motores esofágicos. Objetivo: Determinar la factibilidad de la manometría de alta resolución para el estudio de las características de los trastornos motores esofágicos. Métodos: Se realizó una investigación descriptiva, transversal, en el Centro Nacional de Cirugía de Mínimo Acceso, entre septiembre de 2018 y diciembre de 2019, en 56 pacientes cubanos con diagnóstico de trastorno motor esofágico por manometría de alta resolución, con edades entre 18 y 80 años, que dieron su consentimiento para participar en el estudio. Se excluyeron pacientes con acalasia esofágica y los trastornos menores de la peristalsis. Las variables incluidas fueron: edad, sexo, diagnósticos manométricos y sus características, síntomas, tipos de unión esofagogástrica, diagnósticos imagenológicos o endoscópicos. Para el análisis de los resultados se empleó el porcentaje, medidas de tendencia central y ji cuadrado de Pearson de homogeneidad, con un nivel de significación p 8804; 0,05 y 95 por ciento de confiabilidad. Resultados: Predominó la contractilidad ausente (39,28 por ciento), el sexo femenino (58,9 por ciento) y la disfagia (66,07 por ciento). A la obstrucción al flujo de la unión esofagogástrica correspondió la media de presión de reposo del esfínter esofágico inferior más alta (43,28 mmHg) y la media de la presión de relación integrada por encima de 15 mmHg (38,88 mmHg). El esófago hipercontráctil presentó media de contractilidad distal integrada elevada (5564,25 mmHg/s/cm). Se comprobó la existencia de contracciones rápidas en el espasmo esofágico distal (media de 21,4 cm/ s). Conclusiones: La manometría de alta resolución es factible de ser empleada para el diagnóstico de los trastornos motores esofágicos(AU)

Introduction: High-resolution manometry is the gold standard for the study of esophageal motor disorders. Objective: A descriptive, cross-sectional research was carried out in el Centro Nacional de Cirugía de Mínimo Acceso, between September 2018 and December 2019, in 56 patients, diagnosed with esophageal motor disorder by high-resolution manometry, aged between 18 and 20 years, who gave their consent to participate in the study. Esophageal achalasia and minor peristalsis disorders were excluded. The variables included were: age, sex, manometric diagnoses and their characteristics, symptoms, types of esophagogastric junction, imaging or endoscopic diagnoses. For the analysis of the results, the percentage, measures of central tendency and Pearson's chi square of homogeneity were used, with a level of statistical significance 8804; 0.05 and 95 percent reliability. Development: Absent contractility (39,28 percent), female sex (58,9 percent) and dysphagia (66,07 percent) predominated. The obstruction to the flow of the esophagogastric junction corresponded to the highest mean resting pressure of the lower esophageal sphincter (43,28 mmHg) and the mean integrated pressure ratio above 15 mmHg (38,88 mmHg). The hypercontractile esophagus presented mean high integrated distal contractility (5564,25 mmHg/s/cm). Rapid contractions were found in distal esophageal spasm (mean 21,4 cm/s). Conclusions: High resolution manometry was feasible to be used for the diagnosis of major esophageal motor disorders(AU)

Distúrbios funcionais esofágicos na avaliação pré-operatória de cirurgia bariátrica / Esophageal functional disorders in the pre-operatory evaluation of bariatric surgery

ABSTRACT BACKGROUND: Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. OBJECTIVE: Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. METHODS: Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. RESULTS: 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). CONCLUSION: Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

RESUMO CONTEXTO: A obesidade é fator de risco independente para sintomas esofagianos, doença do refluxo gastroesofágico (DRGE) e alterações motoras. Pacientes com obesidade tipo III, candidatos à cirurgia bariátrica foram submetidos a endoscopia digestiva alta (EDA) e também realizaram esofagomanometria (EMN) e pHmetria prolongada (PHM) como parte da avaliação pré-operatória. OBJETIVO: Em um grupo de pacientes com obesidade tipo III em pré-operatório de cirurgia bariátrica, descrever os achados endoscópicos, manométricos e pHmétricos, correlacionando-os com a presença de sintomas típicos de DRGE. MÉTODOS: Estudo retrospectivo, de pacientes com obesidade tipo III, candidatos a cirurgia bariátrica. A avaliação clínica focalizou a presença de sintomas típicos de DRGE (pirose/regurgitação); todos foram submetidos a EMN, PHM e a maior parte à EDA, realizada previamente. RESULTADOS: Foram incluídos 114 pacientes, 93 (81%) do sexo feminino, média de idade de 36 anos e IMC médio de 45,3. Sintomas típicos de refluxo foram referidos por 43 (38%) pacientes e 71 (62%) eram assintomáticos. EDA foi realizada por 82 (72%) pacientes, havendo anormalidades esofagianas em 36 (42%). Entre os anormais, havia hérnia hiatal (HH) em 36%, esofagite erosiva (EE) em 36% e HH + EE em 28%. A EMN foi anormal em 51/114 (45%). Entre os anormais, predominou o esfíncter esofagiano inferior (EEI) hipotenso em 32%, seguido por motilidade esofagiana ineficaz (MEI) em 25%, esôfago em quebra-nozes (19%), EEI hipotenso + MEI (10%), EEI intra-torácico (6%), EEI hipertenso (4%), aperistalse (2%) e acalasia (2%). Dentre os 43 sintomáticos, 23 (53%) apresentavam EMN anormal, sendo que em 31 dos 71 (44%) assintomáticos a EMN também era anormal (P=0,30). A PHM revelou refluxo anormal em 60 (53%) pacientes. Predominou o refluxo anormal biposicional (42%) seguido do refluxo supino (33%) e refluxo ereto (25%). Dentre os 43 pacientes sintomáticos, 26 (60%) apresentavam PHM anormal, sendo que em 34 dos 71 assintomáticos a PHM também era anormal (48%) - P=0,19. CONCLUSÃO: Alterações manométricas foram comuns em obesidade tipo III, sendo as mais frequentes o EEI hipotenso, seguida de motilidade ineficaz. A maioria dos pacientes era assintomática. Mais da metade dos pacientes apresentou refluxo anormal à PHM. Não houve diferença significativa entre o achado de refluxo anormal e a presença de sintomas. Não houve relação entre o achado de alterações motoras e a presença de sintomas.

Caracterización de los trastornos manométricos esofágicos en pacientes con enfermedad por reflujo gastroesofágico refractario con síntomas esofágicos / Characterization of esophageal motility disorders in refractory gastroesophageal reflux disease patients with esophageal symptoms

Resumen Introducción: La enfermedad por reflujo gastroesofágico (ERGE) refractaria puede conducir a complicaciones potenciales como la esofagitis persistente, estenosis esofágica, anillo de Schatzki y esófago de Barrett. Este estudio describe la motilidad en pacientes con ERGE refractaria y su relación con síntomas esofágicos. Método: Se realizó un estudio observacional analítico a partir de una cohorte retrospectiva en pacientes con diagnóstico de ERGE refractaria y síntomas esofágicos a quienes se les realizó manometría esofágica de alta resolución más impedanciometría. Se describen las características clínicas y demográficas, y la asociación entre los trastornos manométricos y los síntomas esofágicos. Resultados: Se incluyeron 133 pacientes (edad promedio: 54,1 ± 12,5 años). La pirosis y regurgitación (69,2 %) y la disfagia esofágica (13,5 %) fueron los síntomas más comunes. La motilidad normal (75,2 %), el aclaramiento completo del bolo (75,2 %) y la motilidad esofágica inefectiva (MEI) (18 %) fueron los hallazgos manométricos más frecuentes. La unión gastroesofágica tipos II y IIIb estuvieron presentes en el 35,3% y 33,8 % de los casos, respectivamente. La aperistalsis (3,8 %) y el esófago en martillo neumático (Jackhammer; 0,8 %) fueron infrecuentes. El aclaramiento incompleto del bolo se asoció con disfagia esofágica (p = 0,038) y a MEI (p = 0,008). Ningún síntoma esofágico se relacionó significativamente con trastornos de motilidad. Conclusiones: Los resultados de nuestro estudio sugieren que los trastornos de motilidad son infrecuentes en los pacientes con ERGE refractaria. Adicionalmente, sugieren que la presencia de alteraciones de motilidad esofágica no se relaciona con la presencia de síntomas esofágicos y, por tanto, que el tipo de síntoma presentado no permite predecir la existencia de dichos trastornos.

Abstract Introduction: Refractory gastroesophageal reflux disease (GERD) can lead to potential complications such as persistent esophagitis, esophageal stricture, Schatzki ring, and Barrett's esophagus. This study describes motility in patients with refractory GERD, and its association with esophageal symptoms. Materials and methods: An analytical observational study was carried out in a retrospective cohort of patients diagnosed with refractory GERD and esophageal symptoms who underwent high-resolution esophageal manometry and impedance testing. Clinical characteristics, demographics, and the association between motility disorders and esophageal symptoms are described. Results: 133 patients were included (mean age 54.1 ± 12.5 years). Heartburn and regurgitation (69.2%), and esophageal dysphagia (13.5%) were the most common symptoms. Normal motility (75.2%), complete bolus clearance (75.2%), and ineffective esophageal motility (IEM) (18%) were the most frequent manometric findings. Type II and IIIb gastroesophageal junction were observed in 35.3% and 33.8% of the cases, respectively. Esophageal aperistalsis (3.8%) and Jackhammer esophagus (0.8%) were rare findings. Incomplete bolus clearance was associated with esophageal dysphagia (p=0.038) and IEM (p=0.008). No esophageal symptoms were significantly related to motility disorders. Conclusions: The results of the present study suggest that motility disorders are rare in patients with refractory GERD. They also suggest that esophageal motility disorders are not associated with the presence of esophageal symptoms and, therefore, the type of symptom experienced does not allow predicting the existence of such disorders.

EndoFLIP: una nueva tecnología / EndoFLIP: a new technology

Resumen Mediante la distensión de un balón con líquido conductor, la sonda de imagen luminal funcional endoluminal (EndoFLIP) evalúa las propiedades biomecánicas como la distensibilidad, volumen, presión e inclusive diámetros de regiones esfinterianas como la unión gastroesofágica, píloro y ano. La mayor evidencia en la utilidad clínica de la EndoFLIP está en los trastornos de motilidad esofágica, principalmente para identificar acalasia cuando la manometría esofágica de alta resolución y otras imágenes no logran diagnosticarla e inclusive, mediante el programa de FLIP 2.0, caracteriza la acalasia en subtipos a partir de patrones de motilidad del esófago distal en respuesta a la distensión. Se ha demostrado recientemente que la EndoFLIP tiene un rol diagnóstico, pronóstico o terapéutico en otras patologías como la esofagitis eosinofílica, reflujo gastroesofágico, gastroparesia, durante la fundoplicatura y dilatación esofágica.

Abstract EndoFLIP evaluates biomechanical properties such as distensibility, volume, pressure, and even diameters of sphincter regions like the gastroesophageal junction, pylorus, and anus, by distending a balloon with a conductive medium. The best evidence of the clinical utility of EndoFLIP is observed in esophageal motility disorders, mainly when identifying achalasia when high-resolution esophageal manometry and other images fail to diagnose it. Even EndoFLIP 2.0 characterizes achalasia into subtypes based on distal esophageal motility patterns in response to distention. Recently, it has been shown that this system has a diagnostic, prognostic and/or therapeutic role in other diseases such as eosinophilic esophagitis, gastroesophageal reflux, and gastroparesis, and during fundoplication and esophageal dilation.

La manometría de alta resolución en los trastornos motores del esófago Introducción en Cuba / High-resolution manometry for diagnosis of esophageal motor disorders. Introduction in Cuba

RESUMEN: Introducción: La manometría esofágica de alta resolución se considera a nivel internacional como un método óptimo para el diagnóstico de los trastornos motores del esófago, de alta especificidad y sensibilidad. Dada la reciente introducción de la técnica en Cuba, se necesita demostrar su utilidad en nuestro país, donde no existe grado de conocimiento previo sobre cuáles son los parámetros de normalidad, así como los diagnósticos de alta resolución más frecuentes. Objetivo: Determinar la utilidad de la manometría esofágica de alta resolución como estudio diagnóstico para los trastornos motores del esófago en Cuba. Métodos: Se diseñó una investigación aplicada, de desarrollo, realizada en el Centro Nacional de Cirugía de Mínimo Acceso, en La Habana, entre junio de 2017 y junio de 2019, en pacientes a los que se les realizó una manometría esofágica. El universo de pacientes fue 611, a quienes se les registraron las variables en estudio. Resultados: De las 611 manometrías esofágicas, 356 correspondían a mujeres (58,3 por ciento) y 255 a hombres (42,7 por ciento), con un promedio de edad de 47, 44 años respectivamente. La motilidad inefectiva fue el trastorno motor más frecuente (32,73 por ciento). En los pacientes con Enfermedad por Reflujo Gastroesofágico, el principal daño de la barrera antirreflujo fue la presencia de relajaciones transitorias del esfínter esofágico inferior. Predominó la Acalasia tipo II (5,23 por ciento). En estos pacientes se registraron valores de Presión de relajación integrada (IRP) por encima de 21. Conclusiones: Se establecieron valores aplicables a pacientes cubanos, que permiten establecer el diagnóstico por alta resolución(AU)

ABSTRACT Introduction: High-resolution esophageal manometry is considered internationally as an optimal method for diagnosis of esophageal motor disorders. Given the recent introduction of the technique in Cuba, it is necessary to demonstrate its usefulness in our country where there is no prior knowledge about the most frequent parameters of normality and high resolution diagnoses. Objective: To determine the usefulness of high-resolution esophageal manometry as a method for the diagnosis of esophageal motor disorders in Cuba. Material and methods: An applied developmental research was designed and carried out at the National Center for Minimal Access Surgery in Havana between June 2017 and June 2019. The study included patients in whom esophageal manometry was performed. The universe consisted of 611 patients and the variables used in the study were recorded. Results: Of the 611 patients who underwent esophageal manometry, 356 were women (58.26 percent) and 255 were men (42.73 percent), with an average age of 47 and 44 years, respectively. Ineffective motility was the most frequent motor disorder (32,73 percent). In patients with Gastroesophageal Reflux Disease, the main damage of the antireflux barrier was the presence of transient lower esophageal sphincter relaxations. Type II achalasia predominated (5,23 percent). In these patients, integrated relaxation pressure (IRP) values above 21 were recorded. Conclusions: Values applicable to Cuban patients that allow to establish a high-resolution diagnosis were established(AU)

Valores normais da manometria de alta resolução de esôfago: estudo multicêntrico brasileiro / Normal values of esophageal high-resolution manometry: a brazilian multicenter study

ABSTRACT BACKGROUND: The high-resolution manometry has been a significant advance in esophageal diagnostics. There are different types of catheter and systems devices to capture esophageal pressures that generate variable data related to Chicago Classification (CC) and consequently influence normal values results. There are not normative data for the 24-channel water-perfused high-resolution manometry system most used in Brazil with healthy volunteers in supine posture. OBJECTIVE: To determine manometric esophageal normative values for a 24-channel water-perfused high-resolution manometry catheter in supine posture using healthy volunteers according to CC 3.0 parameters. METHODS: A total of 92 volunteers with no gastrointestinal symptoms or medications affecting GI motility underwent esophageal high-resolution manometry by standard protocol. Age, gender and manometry parameters analyzed using Alacer software were collected. The median, range, and 5th and 95th percentiles (where applicable) were obtained for all high-resolution manometry metrics. Normal value percentiles were defined as 95th integrated relaxation pressure, 5th-100th distal contractile integral, and 5th distal latency. RESULTS: The mean age was 40.5±13.2 years. Our normative metrics were integrated relaxation pressure <16 mmHg and distal contractile integral (708-4111 mmHg.cm.s) distal latency was <6 s and peristaltic break size (>4 cm). For EGJ-CI the range 5th-95th was 21.7-86.9 mmHg.cm.s. CONCLUSION: This is the first report of normative data for the 24-channel water-perfused system in supine posture. It revealed higher integrated relaxation pressure and distal latency duration which suggest the need to change CC 3.0 cutoffs for this system. It is observed that there is a tendency that DCI >7000 mmHg.cm.s may represent the lower limit of hypercontractility, and when <700 mmHg.cm.s (<5% percentile) interpreted as ineffective esophageal motility or failcontraction. Also compared to Chicago 3.0, higher integrated relaxation pressure and duration of distal latency were found. We emphasize that these data must be confirmed by future studies.

RESUMO CONTEXTO: A manometria de alta resolução tem sido um avanço significativo nos diagnósticos esofágicos. Existem diferentes tipos de cateteres e sistemas dispositivos para capturar pressões esofágicas que geram dados variáveis relacionados à Classificação de Chicago (CC) e, consequentemente, podem influenciar os resultados de valores da normalidade. Não há dados normativos com voluntários saudáveis na postura supina, para o sistema manométrico sob perfusão em água de 24 canais, o mais utilizado no Brasil. OBJETIVO: Determinar os valores normativos manométricos do esôfago para um cateter sob perfusão de alta resolução de 24 canais na postura supina utilizando-se voluntários saudáveis assintomáticos de acordo com os parâmetros CC. MÉTODOS: Um total de 92 voluntários sem sintomas gastrointestinais ou medicamentos que afetassem a motilidade gastrointestinal foram submetidos à manometria de alta resolução do esôfago por protocolo padrão (Sistema Alacer Multiplex). Foram coletados parâmetros de idade, sexo e os da manometria analisados pelo software Alacer versão 6.2. A mediana, os limites, e 5% e 95% percentis (quando aplicável) foram obtidos para todas as métricas de alta resolução. Os valores normais foram definidos como percentis de 95% da integral da pressão de relaxamento (IRP), 5%-100% da integral contrátil distal (DCI), e 5% latência distal. RESULTADOS: A média de idade foi de 40,5±13,2 anos. As métricas normativas foram definidas como IRP <16 mmHg) e DCI (708-4111 mmHg.cm.s). Para a latência distal foi de 5,8-9,9 s (faixa: 5,3-10,7s). O comprimento total de quebra na contração esofágica foi de 4,0 cm (faixa: 0,1-6,8 cm). Para a EGJ-CI a faixa 5%-95% percentis foi de 21,7-86,9 mmHg.cm.s. CONCLUSÃO: Este é o primeiro relatório de dados normativos para o sistema de 24 canais perfundido por água na postura supina. A partir dos dados encontrados observa-se a possibilidade de alterar os cortes CC 3.0 para este sistema. Observa-se que há uma tendência que DCI >7000 mmHg.cm.s possa representar o limite inferior da hipercontratilidade e quando <700 mmHg.cm.s (<5% percentil) interpretada como motilidade esofágica ineficaz ou contração falha. Também em comparação com Chicago 3.0, foi encontrada maior pressão de relaxamento integrado e duração da latência distal. Ressaltamos que esses dados devem ser confirmados por estudos futuros.

Síndrome de CREST asociado a shock séptico por osteomielitis hematógena aguda / CREST syndrome associated with septic shock due to acute osteomyelitis hematologic

El síndrome de CREST (calcinosis, fenómeno de Raynaud, dismotilidad esofágica, esclerodactilia, telangiectasias) forma parte del espectro clínico de la esclerosis sistémica, enfermedad del colágeno, denominada en la clasificación clínica como esclerodermia cutánea limitada. Se presenta un paciente masculino de 53 años, raza blanca y procedencia rural, que desde hace 10 años presenta poliartritis, cambios en zonas distales de la piel que subyace adherida al hueso, falanges de manos y pies, fenómeno de Raynaud, aparición de nódulos subcutáneos de pequeño tamaño en varias localizaciones, que luego se tornan calcificaciones. Llega con una úlcera en el quinto metatarsiano del pie izquierdo, de 14 meses de evolución con varios ingresos para tratamiento de la lesión con resolución aparente y luego recidiva. Desarrolla un cuadro de osteomielitis hematógena aguda con shock séptico. El tratamiento multidisciplinario y oportuno permitió la sobrevida del paciente(AU)

CREST's Syndrome (calcinosis, Raynaud's phenomenon, dysmotilitic esofhagical, sclerodactilitys, telanghiectasis), the form departs from the clinical spectrum of the Systemic Sclerosis, disease of collagen, named in the clinical classification like cutaneous limited scleroderma. Patient, masculine of 53 years, white race, peasant procedence. 10 years ago with changes at zones level distally of the skin that underlies once the bone was adhered, phalanges of hands and feet, Raynaud's phenomenon so big a child's appearing of subcutaneous nodules at several locations, that next calcifications appear. Ulcer in metatarsal foot left-hand fifth, of 14 months of evolution with multiple entrances for treatment of the lesion with apparent resolution and next relapse. Develop acute osteomyelitis hematologic with septic shock. The multi-disciplinary and opportune treatment enabled the patient's over-life(AU)

Esophageal manometry in systemic sclerosis: findings and association with clinical manifestations

SUMMARY INTRODUCTION Systemic sclerosis (SSC) is an autoimmune disorder that affects several organs of unknown etiology, characterized by vascular damage and fibrosis of the skin and organs. Among the organs involved are the esophagus and the lung. OBJECTIVES To relate the profile of changes in esophageal electromanometry (EM), the profile of skin involvement, interstitial pneumopathy (ILD), and esophageal symptoms in SSC patients. METHODS This is an observational, cross-sectional study carried out at the SSC outpatient clinic of the Hospital de Clínicas of the Federal University of Uberlândia. After approval by the Ethics Committee and signed the terms of consent, 50 patients were initially enrolled, from 04/12/2014 to 06/25/2015. They were submitted to the usual investigations according to the clinical picture. The statistical analysis was descriptive in percentage, means, and standard deviation. The Chi-square test was used to evaluate the relationship between EM, high-resolution tomography, and esophageal symptoms. RESULTS 91.9% of the patients had some manometric alterations. 37.8% had involvement of the esophageal body and lower esophageal sphincter. 37.8% had ILD. 24.3% presented the diffuse form of SSC. No association was found between manometric changes and clinical manifestations (cutaneous, pulmonary, and gastrointestinal symptoms). CONCLUSION The present study confirms that esophageal motility alterations detected by EM are frequent in SSC patients, but may not be related to cutaneous extension involvement, the presence of ILD, or the gastrointestinal complaints of patients.

RESUMO INTRODUÇÃO A esclerose sistêmica (ES) é uma doença autoimune que afeta vários órgãos de etiologia desconhecida, caracterizada por dano vascular e fibrose da pele e órgãos. Entre os órgãos envolvidos estão o esôfago e o pulmão. OBJETIVOS Relacionar o perfil das alterações na eletromanometria (ME), o perfil de acometimento da pele, a pneumopatia intersticial (PI) e os sintomas esofágicos em pacientes com ES. MÉTODO Trata-se de um estudo observacional, transversal, realizado no ambulatório de SSC do Hospital das Clínicas da Universidade Federal de Uberlândia. Após aprovação pelo Comitê de Ética e assinatura dos termos de consentimento, 50 pacientes foram inicialmente convidados, de 04/12/2014 a 25/06/2015. Eles foram submetidos às investigações usuais de acordo com o quadro clínico. A análise estatística foi descritiva em porcentagem, média e desvio padrão. O teste Qui-quadrado foi utilizado para avaliar a relação entre ME, tomografia de alta resolução e sintomas esofágicos. RESULTADOS 91,9% dos pacientes apresentaram alterações manométricas. 37,8% tinham envolvimento do corpo esofágico e do esfíncter esofágico inferior. 37,8% tinham IP. 24,3% apresentaram a forma difusa da ES. Não há associação entre alterações manométricas e manifestações clínicas (sintomas cutâneos, pulmonares e gastrointestinais). CONCLUSÃO O presente estudo confirma que as alterações da motilidade esofágica detectadas pela EM são frequentes em pacientes com SSC, mas podem não estar relacionadas ao envolvimento cutâneo, à de DPI ou às queixas gastrointestinais dos pacientes.

Study of etiology and esophageal motility characteristics of esophagogastric junction outlet obstruction patients / 北京大学学报(医学版)

OBJECTIVE@#To analyze the causes of the esophagogastric junction outlet obstruction (EGJOO) patients, to discuss the differences of the clinical manifestation and esophageal motility characteristics between the anatomic EGJOO (A-EGJOO) and functional EGJOO (F-EGJOO) subgroups, and to search the diagnostic values of the specific metrics for differentiating the subgroups of EGJOO patients.@*METHODS@#For the current retrospective study, all the patients who underwent the esophageal high resonance manometry test were retrospectively analyzed from Jan 2012 to Oct 2018 in Peking University Third Hospital. The EGJOO patients were enrolled in the following research. The clinical characteristics, such as symptoms and causes of the patients were studied. Then the patients were divided into two subgroups as A-EGJOO subgroup and F-EGJOO subgroup. The clinical symptoms and the main manometry metrics were compared between these two subgroups. The significant different metrics between the two groups were selected to draw receiver operating characteristic (ROC) curves and the diagnostic values were analyzed in differentiating the A-EGJOO and F-EGJOO subgroups.@*RESULTS@#The most common symptom of EGJOO was chest pain or chest discomfort (30.63%), then the dysphagia (29.73%), and acid regurgitation/heartburn (27.03%). Non-erosive reflux disease (36.04%) was the most popular cause for EGJOO, then the reflux esophagitis (17.12%). Besides the intra-EGJOO and extra-EGJOO lesions, the connective tissue disease (6.31%) and central nervous diseases (2.70%) were found to be the etiology of EGJOO. The causes of the rest 19 EGJOO were unknown. A-EGJOO patients presented significantly higher intra bolus pressure (IBP) than that of F-EGJOO [6.80 (5.20, 9.20) mmHg vs. 5.10 (3.10, 7.60) mmHg, P=0.016]. The area under curve of IBP was 0.637. When IBP≥5.15 mmHg, the sensitivity was 78.60% and specificity 50.70% to differentiate A- or F-EGJOO.@*CONCLUSION@#Chest pain or chest discomfort was the most common symptom in EGJOO patients. Besides the intraluminal structural disorders, the extra-luminal causes were found in EGJOO patients. A-EGJOO presented higher IBP than that of F-EGJOO patients. The cutoff value of IBP to differentiate A-EGJOO from EGJOO was 5.15 mmHg with sensitivity 78.06% and specificity 50.70%. However for the low area under curve, the diagnostic value of IBP was limited.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus? / A fundoplicatura a nissen melhora a dismotilidade esofágica em pacientes com esôfago de barrett?

ABSTRACT Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett's esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.

RESUMO Objetivo: avaliar a dismotilidade esofágica (DE) e a extensão do esôfago de Barrett (EB) antes e depois da fundoplicatura laparoscópica a Nissen (FLN) em pacientes previamente diagnosticados com EB e DE. Método: vinte e dois pacientes com EB diagnosticada por endoscopia digestiva alta (EDA) com biópsias e DE diagnosticada por manometria esofágica convencional (MEC) foram submetidos a FLN, e acompanhados por avaliações clínicas, endoscopia digestiva alta com biópsias e MEC, por no mínimo 12 meses após o procedimento cirúrgico. Resultados: dezesseis pacientes eram do sexo masculino (72,7%) e seis do feminino (27,3%). A média de idade foi de 55,14 (± 15,52) anos e o seguimento pós-operatório médio foi de 26,2 meses. A endoscopia digestiva alta mostrou que o comprimento médio do EB foi de 4,09 cm no pré-operatório e 3,91 cm no pós-operatório (p = 0,042). A avaliação da dismotilidade esofágica por meio da manometria convencional mostrou que a mediana pré-operatória da pressão de repouso do esfíncter esofágico inferior (PREEI) foi de 9,15 mmHg, e de 13,2 mmHg no pós-operatório (p = 0,006). A mediana pré-operatória da amplitude de contração esofágica foi de 47,85 mmHg, e de 57,50 mmHg no pós-operatório (p = 0,408). A avaliação pré-operatória do peristaltismo esofágico mostrou que 13,6% da amostra apresentava espasmo esofágico difuso e 9,1%, motilidade esofágica ineficaz. No pós-operatório, 4,5% dos pacientes apresentaram espasmo esofágico difuso, 13,6% de aperistalse e 22,7% de atividade motora ineficaz (p = 0,133). Conclusões: a FLN diminuiu a extensão do EB, aumentou a pressão de repouso do EEI e aumentou a amplitude da contração esofágica distal; no entanto, não foi capaz de melhorar a DE.

Síndrome de Boerhaave: uma complicação rara em pós-operatório de cirurgia estética / Boerhaave syndrome: a rare complication of cosmetic surgery

Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave.

Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.

Acalasia, una visión actual / Achalasia, a current view

La palabra 'acalasia' es un neologismo de origen griego, acuñado por el médico inglés Sir Edwin Cooper en 1913, y significa: sin calidad de relajación. La acalasia es una enfermedad que se manifiesta clínicamente por disfagia para sólidos y para líquidos, regurgitación esofágica, dolor retroesternal, tos, broncoaspiración, neumonía, acidez estomacal y pérdida de peso. Su fisiopatología corresponde a la ausencia de peristalsis esofágica e insuficiente relajación del esfínter esofágico inferior. Estas anormalidades motoras se deben a la pérdida de las neuronas mientéricas que coordinan la peristalsis esofágica y la relajación del esfínter esofágico inferior. Fue descrita por primera vez por Sir Thomas Willis en 1674. Aunque actualmente se considera idiopática, se han comenzado a considerar como posibles causas las alteraciones autoinmunitarias y la predisposición genética; además, las infecciones por virus herpes y por virus herpes zóster se han implicado como causas probables. Su incidencia anual oscila entre 0,3 y 1,63 por 100.000 personas en adultos, con una prevalencia anual de 10 en 100.000 habitantes. Afecta por igual a los dos sexos, y el grupo etario más afectado es el de 30 a 60 años. El diagnóstico se sospecha por los síntomas que presenta el paciente, de los cuales la disfagia es el más importante. Se confirma por medio de la endoscopia de las vías digestivas altas, el esofagograma y la manometría de alta resolución. El tratamiento sigue siendo paliativo y se puede orientar por el subtipo de acalasia, según la clasificación de Chicago. Los mejores resultados se obtienen mediante las técnicas de dilatación neumática, miotomía laparoscópica de Heller y, más recientemente, mediante la miotomía endoscópica peroral (Per-Oral Endoscopic Myotomy, POEM), descrita por Haruhiro Inoue en Japón en el año 2008. Aún faltan estudios prospectivos aleatorizados con seguimiento a largo plazo para determinar cuál es la mejor técnica. Se presenta una revisión actualizada del tema

The word achalasia is a neologism of Greek origin, coined by the English physician Sir Edwin Cooper in 1913, and means no quality of relaxation. Achalasia is a disease clinically manifested by dysphagia with both solids and liquids, esophageal regurgitation, retrosternal pain, cough, bronchial aspiration, pneumonia, heartburn and weight loss. Physiopathologically it corresponds to the loss of esophageal peristalsis and to an insufficient relaxation of the lower esophageal sphincter (LES). These motor abnormalities are due to the loss of myenteric neurons that coordinate esophageal peristalsis and relaxation of the LES. First described by Sir Thomas Willis in 1674, and although it is currently considered idiopathic, it has begun to be considered as possible causes autoimmune components and genetic predisposition; viral infections by herpes and chickenpox zoster have also been implicated as probable causes. Its incidence ranges from 0.3 to 1.63 per 100,000 adults, with a prevalence of 10 in 100,000 inhabitants per year. It affects equally any gender, and the age group between 30 and 60 years is the most affected. The diagnosis is suspected based on the symptomatology, with dysphagia being the most important symptom. It is confirmed with the performance of endoscopy of the upper digestive tract, esophagogram and high resolution manometry. The treatment remains palliative, and may be guided by the subtype of achalasia, according to the Chicago classification. The best results are obtained by the techniques of pneumatic dilation, Heller's laparoscopic myotomy, and more recently by the POEM technique (per oral endoscopic myotomy), described in 2008 in Japan by Haruhiro Inoue. There is still a lack of prospective randomized studies with long-term follow-up that determine which is the best technique. An updated review of the subject is presented

Herniorrafia hiatal y fundoplicatura laparoscópica de Toupet en un paciente con esófago corto / Hiatal herniorrhaphy and Toupet laparoscopic fundoplication in a patient with short esophagus

El esófago corto es una complicación infrecuente del reflujo gastroesofágico, polémico para algunos autores. Su diagnóstico se hace de manera intraoperatoria, ante la imposibilidad de conservar un esófago intrabdominal mayor a tres centímetros desde el hiato diafragmático. Algunos expertos niegan la existencia de esta entidad, argumentando que se debe a una mala disección del esófago. En este artículo, se presenta el caso de un paciente sometido a herniorrafia hiatal con colocación de malla, con gran dificultad para conservar una adecuada longitud del esófago abdominal, y que no requirió gastroplastia (AU)

Short esophagus is an uncommon complication of gastroesophageal reflux, controversial for some authors. The diagnosis is made intraoperatively when , the impossibility of leaving an intra-abdominal esophagus longer than 3 cm becomes patent. Some experts, however, doubt about the existence of this entity, arguing that it is due to a bad dissection of the esophagus. In this article, we present the case of a patient where a hiatal herniorraphy was performed with great difficulty to conserve an adequate length of the abdominal esophagus, without requiring gastroplasty (AU)

Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives

Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.

Elevated Intrabolus Pressure Predicts Abnormal Timed Barium Esophagram in Esophagogastric Junction Outflow Obstruction

BACKGROUND/AIMS: Timed barium esophagram (TBE) is used the classification of esophageal motility disorders and assessing esophageal function. Currently, there are no published studies examining the relationship between high-resolution manometry and TBE in patients with esophagogastric junction outflow obstruction (EGJOO). This study seeks to evaluate this relationship and identify manometric variables that may indicate further evaluation using TBE. METHODS: Retrospective review of medical records identified patients with a diagnosis of EGJOO per the Chicago classification version 3.0. TBE was performed using standard protocol. Patients were divided into 2 groups based on complete emptying or persistence of standing barium column at 5 minutes. RESULTS: Eleven patients were identified with EGJOO who underwent both high-resolution manometry and TBE within 3 months. Five patients had no standing barium column at 5 minutes, while 6 patients had a persistent barium column. Mean age of each group was 54.0 years and 57.8 years, respectively. Patients with abnormal TBE were found to have significantly elevated intrabolus pressure (IBP) compared with patients who had a normal TBE. CONCLUSIONS: In our study, we found significant differences in IBP between these patient groups. These findings suggest that patients with EGJOO and elevated IBP may prompt further clinical evaluation with TBE in order to clarify clinical diagnosis and guide therapeutic intervention.

Emerging Issues in Esophageal Motility Diseases / 대한소화기학회지

With the advances in technology and medical knowledge, new diseases are being identified and investigated. Esophageal motility disorders have been re-defined using high-resolution manometry and their pathogenesis are being better understood. The use of opioid analgesics is increasing worldwide, particularly in the United States, but their chronic use can cause opioid-induced esophageal dysfunction, which mimics spastic motor disorders, including achalasia type 3 or 2 and esophagogastric junction outflow obstruction. Eosinophilic esophagitis is identified by eosinophilic infiltration confirmed on a pathological examination. The condition is often associated with esophageal motility abnormalities. On the other hand, recent studies have suggested that muscle-predominant eosinophilic infiltration, eosinophilic esophageal myositis, might manifest as spastic motor disorders, including achalasia or jackhammer esophagus. Lymphocytic esophagitis is an unusual esophageal condition, which is confirmed by the increased number of lymphocytes in the esophageal epithelium. Although several reports have supported the existence of lymphocytic esophagitis, it is still unclear whether lymphocytic esophagitis is a distinct disease entity or another spectrum of other esophageal diseases, such as gastroesophageal reflux disease or eosinophilic esophagitis. This review presents evidence and reports on the emerging issues in esophageal motility disorders, including opioid-induced esophageal dysfunction, eosinophilic esophagitis with eosinophilic esophageal myositis, and lymphocytic esophagitis.

Achalasia Cardia Resulting in Bronchial Obstruction: A Case Series and Literature Review / 대한소화기학회지

Achalasia is a motility disorder of the esophagus that is characterized by loss of ganglionic neurons within the myenteric plexus of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Clinically this disorder presents with simultaneous dysphagia to solids and liquids, and if left untreated, leads to esophageal dilation, which can give rise to many adverse consequences. Extrinsic compression of respiratory structures is one such consequence, and rarely, cases of tracheal compression secondary to achalasia have been reported. However, cases of extrinsic bronchial compression are yet rarer. Here, we present a case series comprised of two patients with achalasia who presented with extrinsic bronchial compression by a dilated esophagus secondary to achalasia.