Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment.

BACKGROUND: Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium. AIMS: We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates. METHODS: Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence. RESULTS: Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months). CONCLUSIONS: (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.

Diseases associated with or mimicking achalasia.

Achalasia may be associated with some rare systemic diseases. In addition, a few conditions produce a syndrome often indistinguishable from achalasia. Most of these diseases are malignant and should be considered in the differential diagnosis of idiopathic achalasia.

Celiac disease is highly prevalent in lymphocytic colitis.

A high frequency of celiac disease is reported in patients with collagenous colitis. Limited information is available on the frequency of celiac disease in lymphocytic colitis. The aim of our study was to determine the prevalence of celiac disease in microscopic colitis (collagenous and lymphocytic colitis). Patients were identified from a pathology registry of microscopic colitis from 1987 to 1999. Pathology reports and medical records were reviewed for previous small bowel biopsies and/or celiac serology. We identified 113 patients with microscopic colitis, and 46 patients underwent a small bowel biopsy and/or celiac serology. Of these, 27 patients had lymphocytic colitis (63% female; age, 58.6 +/- 16.2 years) and 19 patients had collagenous colitis (79% female; age, 61.8 +/- 13.6 years). Small bowel biopsy alone was performed in 28 of 46 patients, celiac serology alone was performed in 10, and both small bowel biopsy and celiac serology were performed in 8. Celiac disease was identified in 4 patients by small bowel histology; all had lymphocytic colitis (4 of 27 patients, 15%). This frequency of celiac disease is significantly higher than the highest reported U.S. prevalence of celiac disease (4/1,000 individuals; p < 0.01). There is a high frequency of celiac disease in patients with lymphocytic colitis. Given the importance of the early detection of celiac disease, it should be excluded in all patients with lymphocytic colitis, particularly if diarrhea does not respond to conventional treatment.

Esophageal diverticula: patient assessment.

Esophageal diverticula are best classified by their anatomic location: pharyngoesophageal (Zenker's diverticula), midthoracic, and epiphrenic. Most diverticula result from esophageal motility disorders. Although some patients are asymptomatic and diverticula are incidental findings, most patients are symptomatic. Dysphagia, regurgitation, and pain are common complaints, however, symptoms are often nonspecific and may be the result of an associated esophageal motility disorder. Contrast radiography is the prime diagnostic tool; evaluation of the diverticulum, associated esophageal abnormalities, and complications are assessed by a barium esophogram. Esophagoscopy adds little to the evaluation of the diverticulum but may be indicated in the assessment of other esophageal abnormalities. Motility studies, which may be difficult or hazardous to perform, are of little use in the diagnosis and treatment of Zenker's diverticula. Manometric evaluation of midthoracic or epiphrenic diverticula usually show an associated motility disorder and may influence treatment decisions.

Colonic epithelial lymphocytosis without a thickened subepithelial collagen table: a clinicopathologic study of 40 cases supporting a heterogeneous entity.

Lymphocytic colitis (LC) is classically described as a triad of chronic nonbloody, watery diarrhea, normal or nearly normal endoscopy findings, and colonic epithelial lymphocytosis without a thickened subepithelial collagen table (SECT). It is unknown how often patients with colonic epithelial lymphocytosis without a thickened SECT actually present with this classic triad. Cases diagnosed histologically as lymphocytic or microscopic colitis were reviewed. Criteria for inclusion were the presence of at least 15 surface lymphocytes per 100 epithelial cells and the absence of a thickened SECT (<12 microm). Clinical features and course were recorded by chart review and telephone follow-up. Forty patients met the inclusion criteria, including 25 women and 15 men with a mean age of 63.2 years (range, 25-83 years). Twenty-eight patients had the classic triad and were designated as having classic LC. The other 12 patients fulfilled the histologic criteria but not the clinical or endoscopic criteria for classic LC and were classified as having atypical LC (constipation, five patients; macroscopic colitis at endoscopy, five patients; hematochezia, one patient; and incidental finding, one patient). Clinically, patients with classic LC were predominantly women and had a higher incidence of autoimmune disease (p = 0.03) than did those with atypical LC. Histologically, surface eosinophilia was significantly greater in patients with classic LC (p = 0.04). Twenty patients were using nonsteroidal antiinflammatory drugs at the time of their colonic biopsy. Surface epithelial lymphocyte counts were higher in these patients, particularly in the distal sigmoid colon (p = 0.02). Fourteen patients had associated autoimmune disease, including three patients with sprue diagnosed by small bowel biopsy, all of whom responded to gluten withdrawal. Diarrhea present in 25 patients, without documented evidence of celiac sprue, was self-limited in five, resolved with treatment in three, required intermittent treatment in eight, daily treatment in five, and was refractory to treatment in four. All eight patients who experienced spontaneous or treatment-related symptom resolution had classic LC. No histologic feature correlated with clinical course. In conclusion, our study shows that colonic epithelial lymphocytosis without a thickened SECT is a histologic finding seen in a heterogeneous group of patients. Within this heterogeneous group is a distinct subset of patients who have the classic clinicopathologic triad of LC. This subset of patients has striking similarities to patients with collagenous colitis, lending further support to a close relationship between these two entities. Atypical LC comprises a heterogeneous group and includes patients with idiopathic constipation, coexisting LC and inflammatory bowel disease, and possibly infectious colitides. Because of the clinical heterogeneity among our study population, the descriptive term colonic epithelial lymphocytosis may be a more prudent diagnosis than lymphocytic colitis in the absence of adequate clinical information.

Long-term outcome of achalasia treatment: the need for closer follow-up.

Treatment of achalasia includes pneumatic dilation (PD) and surgical myotomy (SM). Success rates range from 32% to 98% and are mostly based on symptomatic response. Our aims were to determine the long-term outcome of patients treated for achalasia and the adequacy of long-term follow-up. Patients treated with PD or SM between 1986 and 1990 were contacted by telephone after a minimum of 4 years after treatment, and asked about symptoms and need for retreatment since their discharge from our institution. Symptomatic response was classified as excellent/good or fair/poor using the Vantrappen score. Treatment was deemed a failure if patients were symptomatic on callback, needed retreatment, technical problems occurred during PD, or perforation occurred. Forty-seven PD patients and 15 SM patients were studied. There were no significant differences in clinical parameters between groups. Median time to callback was 82 and 73 months, respectively. Failure rates were high, respectively 74% and 67%. Importantly, 38% of PD and 33% of SM patients failed to seek help despite symptom recurrence. Achalasia treatment failures are higher than anticipated. This may be because of the lack of routine follow-up as well as patients' failure to seek help when symptoms recur. Achalasia patients need closer follow-up and may benefit from early intervention based on objective tests rather than symptoms alone.

Viridans streptococcal bacteremia after esophageal stricture dilation.

BACKGROUND: The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation. METHODS: Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation. RESULTS: A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients (p = 0. 001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation. CONCLUSIONS: These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis.

Zenker's diverticulum.

Zenker's diverticulum is a pouch protruding posteriorly above the upper esophageal sphincter, in the Killian's triangle, an area of relative weakness. Zenker's diverticulum was thought, for many years, to occur as a result of cricopharyngeal incoordination but more recent evidence points to poor upper sphincter compliance with diminished sphincter opening and increased hypopharyngeal pressures. Small Zenker's diverticula may be asymptomatic. As they become larger, symptoms include dysphagia, food regurgitation, and a sensation of globus. The best diagnostic method is a barium swallow with attention to the cricopharyngeal area. Although gastroesophageal reflux may be responsible for many throat symptoms, the relationship of reflux to the pathogenesis of Zenker's diverticulum is speculative. The treatment of Zenker's diverticulum is surgical. There have been many variations in technique over the years. Diverticulectomy with cricopharyngeal myotomy remains the most frequently performed operation. Endoscopic treatment with or without laser stapling has been reported but is not popular in the United States.

Effect of pneumatic dilation on gastroesophageal reflux in achalasia.

The aims of this study were to assess the effect of pneumatic dilation on gastroesophageal reflux in achalasia, differentiate esophageal acid due to lactate from acid due to gastroesophageal reflux, and determine if chest pain and heartburn are reliable indicators of gastroesophageal reflux. Eight untreated achalasia patients underwent pre- and postdilation esophageal fluid/food residue lactate and pH analysis, esophageal manometry, 24-hr pH monitoring, and symptom assessment. All patients had a successful clinical outcome and a decrease in lower esophageal sphincter pressure from 29.1 +/- 12.7 to 14.7 +/- 3.8 mm Hg (mean +/- SD; P = 0.04). Abnormal acid exposure was present in two patients before and two patients after dilation. Postdilation acid exposure was mild. Lactate was detected before dilation in all patients. A lactate concentration >2 mmol/liter was associated with acidic residue and one abnormal 24-hr pH profile. There was no correlation between an abnormal 24-hr pH test and age, lower esophageal sphincter pressure, or duration of symptoms prior to treatment. Chest pain and heartburn were unrelated to drops in pH. Gastroesophageal reflux is rare in untreated achalasia and esophageal acidity may result from ingestion of acidic foods or production of lactate. Mild gastroesophageal reflux occurs after dilation but is of no clinical significance. Chest pain and heartburn are not indicators of acid reflux in achalasia.

Pharmacology of the gastrointestinal tract.

Oral health care providers must have a basic understanding of gastrointestinal and hepatic dysfunction, principles of medical management, and the influence these factors may have on the dental management of these patients and on the selection and dosage regimen of drugs for the treatment of oral/odontogenic conditions.

Achalasia.

Achalasia is a primary esophageal motor disorder characterized by lack of esophageal peristalsis and poor lower esophageal sphincter (LES) relaxation. Clinically, achalasia manifests as progressive dysphagia to solids and liquids and mild weight loss. Predisposition to esophageal cancer is not prevalent, but certain tumors may mimic achalasia. The diagnosis of achalasia is relatively easy to make with a good history, radiography, and esophageal motility testing. The esophagogram reveals a typical bird-beak narrowing of the esophagogastric junction and esophageal dilation, the degree of which depends on the stage of the disease. Esophageal manometry reveals poor LES relaxation, aperistalsis, and often elevated intraesophageal pressure. Endoscopic examination is important to rule out malignancy as the cause of achalasia. The traditional treatment of achalasia is forceful dilation of the LES. Bougienage may be helpful in some cases. Pharmacological agents, such as nitroglycerin and calcium channel blockers, provide some relief by decreasing LES pressure. However, they are not a viable, long-term choice. Surgical myotomy offers slightly better results than pneumatic dilation, but it is accompanied by some increased gastroesophageal reflux. Laparoscopic and thoroscopic myotomy are in their infancy, and, if successful, they will make surgical treatment much more attractive. Intrasphincteric botulinum toxin injection is the newest form of therapy. Its safety and ease of administration are very encouraging, but long-term results are not available.

Collagenous colitis. A treatable disease with an elusive diagnosis.

Collagenous colitis is associated with normal endoscopy examination and peculiar histopathological changes. The natural history and optimal treatment are not well defined. Our objectives were to analyze the symptomatology of collagenous colitis, determine the natural history, and response to treatment. All patients with collagenous colitis from 1978 to 1992 were studied. Demographic data, symptomatology, associated conditions, colonoscopic findings, and pathology specimens were reviewed. Clinical improvement was classified as none, partial, or complete. Nineteen patients were identified, mainly white females over age 50. Mean follow-up was 22.6 months. Symptom duration was 37 months (range 4 months to 15 years). Symptoms were intermittent diarrhea (19), with a predominant nocturnal component (13); abdominal pain (15); and mild weight loss and incontinence (8). Colonoscopy was normal in 12 patients. Segmental mucosal edema and loss of vasculature pattern were present in seven. Antiperistaltic agents were used in 17 patients with no improvement (15), partial resolution (1), and complete resolution (1). Eight nonresponders received sulfasalazine. Responses were none (6) or complete (2). Ten patients received steroids (10-20 mg/day). One failed to respond. Nine initially responded completely but two relapsed. Seven patients who did not respond to any type of treatment improved eventually, two partially and five completely. These patients were younger (54.3 vs 68.3 years, P = 0.04) and symptom duration was shorter (25.4 vs 44.5 months, P = 0.38) than the rest of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Endosonographic evaluation of the patient with achalasia: appearance of the esophagus using the echoendoscope.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) provides high-resolution images of the esophageal wall and adjacent structures. The purpose of this study was to evaluate the usefulness of EUS using the echoendoscope in the evaluation of patients with achalasia. PATIENTS AND METHODS: Seventeen patients with achalasia underwent esophagogastroduodenoscopy (EGD), esophageal manometery, and EUS. The esophageal wall thickness was measured endosonographically in four quadrants at the gastroesophageal junction (GEJ) and at 1 cm intervals proximally. Of the 17 patients evaluated, five had a tortuous esophagus (Group A) and 12 had a relatively straight esophagus (Group B). Six patients without esophageal symptoms served as controls (Group C). RESULTS: There was no significant difference in the mean esophageal wall thickness measured at the GEJ between the groups (4.0 mm, 3.3 mm, and 2.9 mm for Groups A, B, and C, respectively). Esophageal wall thickness was significantly greater in Group A than Group C when measured 2, 3, and 4 cm above the GEJ (4.2 mm vs. 2.8 mm; 4.1 mm vs. 2.4 mm; 4.0 mm vs. 2.4 mm, respectively) (p < .05). When measured 2 cm above the GEJ, the esophageal wall in Group A patients was significantly thicker (4.2 mm) than in patients in either Group B (3.2 mm) or Group C (2.8 mm) (p < 0.05). CONCLUSIONS: The appearance of esophageal wall thickening was common in patients with achalasia. Positioning of the echoendoscope in some patients with an irregularly-shaped, tortuous esophagus may result in tangential imaging and the production of artifacts simulating submucosal lesions. The production of such imaging artifacts suggests that caution must be exercise when EUS with the echoendoscope is used to evaluate patients with achalasia and a tortuous esophagus. Based on the present level of knowledge, EUS is not recommended in the routine evaluation of patients with achalasia.

Risk of extraesophageal malignancy in patients with adenocarcinoma arising in Barrett's esophagus.

OBJECTIVES: It has been suggested that the presence of Barrett's mucosa is a marker for potential malignancy in other organs. Our objective was to study subjects with adenocarcinoma of the esophagus arising in Barrett's epithelium. METHODS: We reviewed the medical records of patients with esophageal adenocarcinoma, with esophageal squamous cell carcinoma, and with no esophageal pathology and recorded the occurrence of extraesophageal malignancies and the heavy use of tobacco and alcohol. RESULTS: The prevalence of extraesophageal malignancies was not higher in patients with esophageal adenocarcinoma (15%) than in patients in either control group (14% each). Patients with either type of cancer of the esophagus had higher rates of tobacco and alcohol use than normal controls (tobacco: p = 0.02 and p < 0.01 for adenocarcinoma and squamous cell carcinoma, respectively, vs. normal controls; alcohol: p < 0.01 for each esophageal malignancy vs. normal controls). The rate of tobacco and alcohol use was higher in patients with esophageal squamous cell carcinoma than in those with adenocarcinoma, but only the difference in alcohol consumption was statistically significant (p < 0.01). CONCLUSION: Patients with adenocarcinoma of the esophagus are not at higher risk for development of extraesophageal malignancy. This observation applies to both those with and without underlying Barrett's epithelium. Alcohol and tobacco use appear to be related to the malignant transformation of esophageal epithelium.

Follow-up of patients with noncardiac chest pain. Value of esophageal testing.

Noncardiac chest pain may be a debilitating symptom. The utility of esophageal testing to enhance patient quality of life has been inconclusive. The purpose of this study was to evaluate prospectively the impact of esophageal testing on patient well-being. Fifty-five patients undergoing esophageal testing were available for follow-up. Seventeen (31%) patients were classified in group 1: considered to have the esophagus as a likely etiology because of positive testing; 14 (25%) in group 2: possible contribution of the esophagus to symptoms; and 24 (44%) in group 3: unlikely esophageal etiology with negative testing. Thirty-four patients continued to be symptomatic at follow-up (median 112 days). The change in pain intensity from pretesting to follow-up was significant only for group 3 (P = 0.001). There was a decline in hospital utilization in all three groups. (Emergency room visit P = 0.004 group 1, hospital admissions P = 0.02, group 3). Group 1 and 2 patients tended to miss less work, social functions, and activities. Group 3 continued to stay in bed and avoid normal functions. Nine of 34 (26%) patients who were symptomatic at follow-up identified the esophagus as the source of symptoms. In all, 42% of group 1, 29% of group 2, and 18% of group 3 patients considered the esophagus to be the source of their symptoms. We conclude that esophageal testing does not always prevent the persistence of symptoms and that patients have misperceptions about testing results on follow-up.