Surgical myotomy in patients with high-amplitude peristaltic esophageal contractions. Manometric and clinical effects.

High-amplitude peristaltic esophageal contractions, or the nutcracker esophagus, may be associated with chest pain or dysphagia. Medical treatment for this disorder is sometimes not satisfactory. We report the manometric and clinical effects of myotomy in four patients with high-amplitude peristaltic contractions who underwent surgery because of the severity of their symptoms and recalcitrance to various medical treatments. Manometry 1-5 years after surgery showed a reduction in amplitude, duration, and percent bipeaked waves at 5 and 10 cm above the lower esophageal sphincter. Peristalsis was abolished or decreased in the distal 10 cm of the esophageal body but was not affected more proximally. Lower esophageal sphincter pressure was decreased in all patients. The manometric changes were least marked in one patient, who was the only one who had some chest pain when last seen five years after myotomy. We conclude that in severely symptomatic patients with high-amplitude peristaltic contractions, myotomy results in marked manometric changes and marked clinical improvement. Patients with this disorder and whose chest pain is recalcitrant to extensive medical therapy may be successfully treated by surgical myotomy.

The significance of intraepithelial eosinophils in the histologic diagnosis of gastroesophageal reflux.

Detection of intraepithelial eosinophils in esophageal mucosal biopsies has been suggested as histologic evidence of symptomatic gastroesophageal reflux (GER) disease in both children and adults. Previous studies have primarily examined symptomatic persons, and only one study included a comparison with normal controls. In the present study, the authors examined esophageal mucosal biopsies obtained by the hydraulic suction technic for the presence of intraepithelial eosinophils from 73 adult patients with subjective and objective evidence of GER disease and 12 asymptomatic adult volunteers in whom a series of esophageal function tests were normal. Intraepithelial eosinophils were identified in 23 (31.5%) of adult patients and in 4 (33.3%) of the asymptomatic volunteers. No clinical aspects in the GER patients correlated with the presence of eosinophils. By crude quantitation, rare eosinophils added little to more conventional assessment of histologic esophagitis and were present in one-third of normal subjects. The authors conclude that rare eosinophils in esophageal biopsies may not be a reliable criterion for the histologic assessment of GER disease.