Peroral endoscopic myotomy for esophageal motility disorders.

BACKGROUND: Esophageal motility disorders which include achalasia, esophagogastric junction outflow obstruction (EGJ outflow obstruction), jackhammer esophagus (JE), distal esophageal spasm (DES), etc. are rare disease of unknown causes. The diagnosis is based on endoscopy, barium meal, and high-resolution manometry (HRM). With the development of endoscopy, peroral endoscopic myotomy (POEM) has emerged as a standard method for the treatment of achalasia. PURPOSE: The purpose of this article is to enable gastroenterologists to have a more comprehensive understanding of the application status, technical characteristics, clinical efficacy and future prospect of POEM in the treatment of esophageal motility disorders. METHODS: Through a large number of reading literature, combined with clinical practice, summary and analysis of the indications, procedure, efficacy, complications, and controversies of POEM in the treatment of esophageal motility disorders, as well as the current and future perspectives of POEM were studied. RESULTS: POEM is safe and effective in the treatment of esophageal motility disorders, but the GERD reflux rate is higher. CONCLUSIONS: POEM can be a new option for the treatment of esophageal movement disorders, but large sample, multi-center, long-term study reports are needed, and it promotes the development of NOTES technology.

Bezoar esofágico en paciente con espasmo esofágico difuso / Esophageal bezoar in a patient with a diffuse esophageal spasm

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Distal esophageal spasm.

PURPOSE OF REVIEW: Distal esophageal spasm (DES) is a rare esophageal motility disorder associated with dysphagia and chest pain. In 2011, the diagnosis of DES was refined based on the occurrence of premature (rather than rapid) contractions by high-resolution manometry. New therapeutic options have also been recently proposed. Thus, a review on DES incorporating publications since 2012 is timely because of these revisions in definition and management. RECENT FINDINGS: DES remains a heterogeneous clinical disorder. Its pathophysiology is still debated and DES might be related to achalasia. Alternatively, it might be secondary to medications, especially opiates. Endoscopic ultrasound might be informative diagnostically by demonstrating muscularis propria hypertrophy and thickening. Botulinum toxin injection in the esophageal body has been shown superior to placebo to relieve symptoms associated with DES. Finally, per oral endoscopic myotomy is a promising therapeutic approach, but may be less effective in DES than in achalasia. SUMMARY: The diagnosis of DES should lead to a systematic search for medication that might promote the occurrence of esophageal dysmotility. Endoscopic treatment of DES (botulinum toxin injection or per oral endoscopic myotomy) should be further evaluated in controlled studies using current diagnostic criteria by high-resolution manometry.

[Clinical and pathogenetic features of esophageal spasm].

AIM: To comparatively analyze clinical manifestations in patients with primary esophageal spasm (ES) and its concurrence with gastroesophageal reflux disease (GERD) and the results of their instrumental examinations and psychodiagnostic tests. SUBJECTS AND METHODS: A total of 104 patients with the clinical and manometric signs of ES were examined and divided into two groups: 1) 42 patients with primary ES; 2) 62 patients with ES concurrent with GERD. The examination encompassed esophageal manometry, esophagogastroduodenoscopy, 24-hour pH metry, and an interview using a questionnaire to identify autonomic disorders, and the Mini-Mult test. RESULTS: The patients with primary ES compared to those with ES concurrent with GERD significantly more frequently showed severe pain syndrome (p = 0.009) and a paradoxical dysphagia pattern (p = 0.03); manometry revealed an incoordination in the motility of the entire esophagus (p = 0.001). Comparison of the statistical series of values for contraction amplitude and duration in the distal esophagus found no significant difference in the patients of both groups. Autonomic disturbances were detected in 76.0% of the patients with ES; but the intergroup differences were insignificant. Mental maladaptation was observed in 81.7% of the patients in the absence of intergroup differences. CONCLUSION: The etiopathogenetic factor of ES is a psychoautonomic response to chronic stress in both primary ES and its concurrence with GERD. The reflux of gastric contents into the esophagus does not appear to be one of the leading causes of ES. In primary ES, esophageal motor function is generally impaired to a much greater extent than that in ES concurrent with GERD. The degree of motor disorders is embodied in the specific clinical features of the disease.

Distal esophageal spasm: an update.

Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.

Insights gained from symptom evaluation of esophageal motility disorders: a review of 4,215 patients.

BACKGROUND/AIMS: Achalasia (Ach), diffuse esophageal spasm (DES), nutcracker esophagus (NE), and nonspecific motility disorder (NSMD) are described primary esophageal body motility disorders; however, their clinical symptom correlation is poorly understood. The aim of this study is to examine the association between a patient's presenting symptoms and their manometric diagnosis. METHODS: Manometric findings and reported symptoms of all patients undergoing esophageal manometry at the Creighton University Medical Center were prospectively entered in a database. Twenty-four-year data from 1984 through 2008 were accessed and analyzed. RESULTS: Of the 4,215 patients, 130 (3.1%) had Ach, 192 (4.6%) had DES, 290 (6.9%) had NE, 508 (12.1%) had NSMD, and 3,095 (73.4%) had normal esophageal body motility. There was significant symptom overlap between the groups. Ach and DES had a similar symptom distribution, with dysphagia being the predominant symptom. Patients with NE, normal body motility, and NSMD presented predominantly with reflux symptoms. There was an increasing prevalence of esophageal dysmotility (DES and NSMD) with age, and women were found to be more likely to have NE than men. CONCLUSION: In an individual, reported symptoms do not correlate with their manometric diagnosis in a predictable fashion, and a thorough physiological assessment should be obtained to understand and diagnose the disease process. Esophageal motility deteriorates with age.

Diffuse esophageal spasm.

The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.

Effects of hyperbaric oxygen therapy on caustic esophageal injury in rats.

BACKGROUND/PURPOSE: Caustic esophageal burn is a serious problem in pediatric surgery. Even though many clinical and experimental studies had been performed, the complication rate could not be reduced to a satisfying level. In this study, the authors evaluated the effects of hyperbaric oxygen (HBO) therapy in caustic esophageal burn in rats. METHODS: Rats were divided into 4 groups, and caustic burn at the distal esophagus was created by applying 50% NaOH for 3 minutes in all groups. The first and third groups did not receive HBO therapy. HBO therapy was applied to the second group for 2 days and to the fourth group for 28 days. To evaluate the effects of short-term HBO therapy, the first 2 groups were compared for ulceration, inflammation, and submucosal vascular thrombosis after 2 days. The third and fourth groups were compared for the long-term effects of HBO therapy. Rats in these groups were killed after 28 days and compared for the collagen content, weight, and mortality rate. RESULTS: In the second group, which received 2 days of HBO therapy, ulcer depth and vascular thrombosis were significantly lower than these in the first group (P =.022 and P =.020, respectively). The fourth group, which received 4 weeks of HBO therapy, had a significantly reduced mortality rate, weight loss, and collagen score and hydroxyproline level if compared with the third group (P =.035; P =.016; P =.028; and P =.033, respectively). CONCLUSIONS: These results indicate that HBO therapy is useful in caustic esophageal burn both in short-term and long-term use.

Comparison of the esophageal manometric characteristics of idiopathic and reflux-associated esophageal spasm: evaluation by 24-hour ambulatory esophageal motility and pH monitoring.

Diffuse esophageal spasm (DES) is a typical esophageal dysfunction, but its cause is unknown. DES has been classified into reflux-associated esophageal spasm (RDES), caused by acid exposure, and idiopathic esophageal spasm (IDES), of unknown causes. The differences in esophageal motility pattern between the RDES and IDES are clues to elucidating the pathogenesis of DES. Although 24-hr ambulatory esophageal motility and pH monitoring is considered a feasible method for evaluating gastroesophageal reflux and esophageal function, most researchers previously defined the RDES as DES accompanied by esophagitis and heartburn using standard manometry over a short time frame. To clarify the pathogenesis of RDES, we did this research using 24-hr ambulatory esophageal motility and pH monitoring. The investigation included 25 normal controls and 116 patients with upper digestive symptoms. Among the 116 patients, 45 had DES (11 RDES, 30 IDES, and DES-GERD coexistence). Patients with RDES showed a significantly higher frequency of simultaneous contractions than did patients with IDES. Heartburn has been said to be peculiar to RDES, but also occurred in 12.5% of IDES. No significant differences in the mean pH of the esophagus during acid reflux were found between the RDES and IDES patients. Based on the results, we have proposed a refined definition of RDES.

Manometric abnormalities of the oesophagus in patients with Parkinson's disease.

Dysphagia in Parkinson's disease (PD) is known to correlate with abnormalities of oropharyngeal function. Oesophageal abnormalities have not been previously demonstrated to correlate with dysphagia. The aim of the study was to determine if motor dysfunction of the oesophageal body correlates with dysphagia or disease severity in PD. Twenty-two patients with PD were assessed for the severity of their dysphagia (scale of 1-7) and severity of PD (Hoehn and Yahr scale 1-4). All underwent oesophageal manometry. Dysphagia was present daily in 10 patients (45%). Parkinson's disease was graded as severe (Hoehn and Yahr > or =3) in eight (36%) patients. Oesophageal manometry was abnormal in 16 (73%) patients. Thirteen patients had either complete aperistalsis or multiple simultaneous contractions (diffuse oesophageal spasm). These findings were significantly more common in patients with daily dysphagia (90% vs. 33%; P < 0.005), and were not related to duration or severity of PD. We conclude that the presence of aperistalsis or multiple simultaneous contractions in the oesophagus does correlate with dysphagia and is independent of PD severity or duration. This may reflect selective involvement of either the dorsal motor nucleus of the vagus or the oesophageal myenteric plexus.

Manifestaçöes clínicas dos distúrbios motores esofagianos / Clinical presentation of esophageal motor disorders

Os distúrbios motores esofagianos representam uma disfunçäo da motilidade do órgäo com alteraçöes na peristalse do corpo esofagiano e/ou no funcionamento dos seus esfíncteres. Apresentam como principais sintomas, disfagia e dor torácica, por vezes com características semelhantes àquelas observadas quando há o comprometimento orgânico do esôfago. Portanto, o reconhecimento do seu quadro clínico é importante para o diagnóstico diferencial com outras enfermidades e para o adequado tratamento dos pacientes.(au)

GERD progressing to diffuse esophageal spasm and then to achalasia.

The pathophysiology of achalasia is not completely understood. Several reports have suggested that esophageal motility disorders may progress from one type to another. We report a patient with symptoms and esophageal motility findings consistent with gastroesophageal reflux who subsequently developed a diffuse esophageal spasm and then achalasia. We believe this to be the first report showing such a progression in esophageal motility.