Management of primary achalasia: The role of endoscopy.

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.

[Effectiveness of maintenance azathioprine therapy without oral cyclosporine after severe attacks of ulcerative colitis refractory to endovenous steroids]. / Eficacia del mantenimiento con azatioprina sin ciclosporina oral tras un brote grave de colitis ulcerosa refractario a esteroides intravenosos.

INTRODUCTION: Intravenous (i.v.) cyclosporine (CsA) has proved effective in controlling acute attacks of ulcerative colitis unresponsive to IV steroids. After the initial response to i.v. CsA, two alternatives for maintaining remission have been proposed: either double or triple association with immunosuppressors. The aim of this study was to evaluate the effectiveness of i.v. CsA, its adverse effects, and the subsequent long-term effectiveness of azathioprine/6-mercaptopurine without oral CsA. MATERIAL AND METHODS: Intravenous CsA was administered for 10 days, at a dose of 4 mg/kg per day, to 20 patients diagnosed with a severe attack of ulcerative colitis who did not respond to IV steroid treatment. Patients who responded to CsA and could be discharged were administered azathioprine or 6-mercaptopurine associated with a decreasing dose of oral steroids, without oral CsA. RESULTS: Sixty per cent (12/20) of the patients showed clinical-biological improvement after CsA administration, thus avoiding colectomy, and were discharged from hospital. Nine of the 12 responders (three withdrew from the study) were followed-up long term. Of these nine patients, four (44.4%) underwent colectomy, all before the sixth month of discharge. All adverse effects were mild, except for one death. CONCLUSIONS: Intravenous CsA is effective in inducing remission of ulcerative colitis in severe attacks resistant to i.v. steroids. When treatment with azathioprine is administered without oral CsA, patients requiring colectomy need this procedure within the first 6 months of discharge.

Eficacia del mantenimiento con azatioprina sin ciclosporina oral tras un brote grave de colitis ulcerosa refractario a esteroides intravenosos / Effectiveness of maintenance azathioprine therapy without oral cyclosporine after severe attacks of ulcerative colitis refractory to endovenous steroids

INTRODUCCIÓN: La ciclosporina (CyA) intravenosa (i.v.) hademostrado ser eficaz en el control de los brotes agudos gravesde colitis ulcerosa que no responden a esteroides i.v.Tras la respuesta inicial a la CyA i.v., se han propuesto dosalternativas para mantener la remisión, la doble o triple asociaciónde inmunosupresores. Los objetivos de nuestro estudiohan sido valorar la eficacia de CyA i.v., sus efectos secundariosy la efectividad posterior a largo plazo de laazatioprina/6-mercaptopurina sin CyA oral.MATERIAL Y MÉTODOS: Se administró CyA i.v. durante 10días, en dosis de 4 mg/kg/día a 20 pacientes diagnosticadosde colitis ulcerosa en brote grave y que no respondieron atratamiento con esteroides i.v. A los que respondieron y pudieronser dados de alta se les administró azatioprina o 6-mercaptopurina asociadas a esteroides orales en pauta descendentey sin CyA oral.RESULTADOS: El 60% (12/20) de los pacientes presentó unamejoría clínico-biológica tras la administración de CyA, loque permitió evitar la colectomía y que fueran dados de altahospitalaria. Se siguieron a largo plazo 9 de los 12 pacientesque respondieron (3 se excluyeron del estudio), y de ellos 4(44,4%) tuvieron que ser colectomizados, todos antes delsexto mes del alta. Los efectos secundarios fueron todos leves,excepto un fallecimiento.CONCLUSIONES: La CyA i.v. es eficaz para inducir la remisiónde la colitis ulcerosa en los brotes graves resistentes aesteroides i.v. Con la estrategia de administrar azatioprinasin CyA oral, los pacientes que requieren colectomía la precisanen los primeros 6 meses tras el alta (AU)

INTRODUCTION: Intravenous (i.v.) cyclosporine (CsA) hasproved effective in controlling acute attacks of ulcerative colitisunresponsive to IV steroids. After the initial response toi.v. CsA, two alternatives for maintaining remission havebeen proposed: either double or triple association with immunosuppressors.The aim of this study was to evaluate theeffectiveness of i.v. CsA, its adverse effects, and the subsequentlong-term effectiveness of azathioprine/6-mercaptopurinewithout oral CsA.MATERIAL AND METHODS: Intravenous CsA was administeredfor 10 days, at a dose of 4 mg/kg per day, to 20 patientsdiagnosed with a severe attack of ulcerative colitis who didnot respond to IV steroid treatment. Patients who respondedto CsA and could be discharged were administeredazathioprine or 6-mercaptopurine associated with a decreasingdose of oral steroids, without oral CsA.RESULTS: Sixty per cent (12/20) of the patients showed clinical-biological improvement after CsA administration, thusavoiding colectomy, and were discharged from hospital. Nineof the 12 responders (three withdrew from the study) werefollowed-up long term. Of these nine patients, four (44.4%)underwent colectomy, all before the sixth month of discharge.All adverse effects were mild, except for one death.CONCLUSIONS: Intravenous CsA is effective in inducing remissionof ulcerative colitis in severe attacks resistant to i.v.steroids. When treatment with azathioprine is administeredwithout oral CsA, patients requiring colectomy need thisprocedure within the first 6 months of discharge (AU)