Difference of achalasia subtypes based on clinical symptoms, radiographic findings, and stasis scores. / Diferencia de subtipos de acalasia basados en síntomas clínicos, hallazgos radiográficos y puntajes de estasis.

INTRODUCTION: Three subtypes of achalasia have been defined through high-resolution esophageal manometry: subtype i shows no pressurization with swallows, subtype ii has increased isobaric panesophageal pressure, and subtype iii has distal esophageal spastic non-isobaric contractions. Studies describing the subtypes based on radiographic findings, clinical symptoms, and stasis scores are limited. AIM: To determine the differences in clinical symptoms, radiographic findings, and stasis scores for the 3 achalasia subtypes. METHODS: Patients undergoing high-resolution esophageal manometry received a questionnaire about current symptoms and previous treatments. The questions included the presence of symptoms and their severity. Barium swallow tests were performed before the high-resolution esophageal manometry study to evaluate the maximum esophageal diameter. Stasis scores were calculated using the transit patterns on high-resolution esophageal manometry. RESULTS: One hundred and eight patients with high-resolution esophageal manometry diagnosis of achalasia (n=8, subtype i; n=84, subtype ii; n=16, subtype iii) within the time frame of 1/2012-6/2015 were included in the study. Sex distribution was similar between the subtypes. Patient age was younger for subtype i (38±16 years), compared with subtypes ii (55±17 years) and iii (63±17 years) (P=.03). Esophageal symptoms did not differ between subtypes regarding the severity of nausea, chest pain, coughing, and heartburn, except for increased vomiting severity in subtype i (2.8±1.4 vs. 1.4±1.4 vs. 1.2±1.2, P<.01). A significant radiographic difference in esophageal dilation was seen between subtypes ii and iii (35.1±14.4 vs. 24.0±7.2mm, P=.023). Stasis scores did not significantly differ between the subtypes. CONCLUSIONS: Achalasia subtypes had similar clinical symptoms, except for increased vomiting severity in subtype i. The maximum esophageal diameter in subtype ii was significantly greater than in subtype iii. Esophageal stasis scores were similar. Thus, high-resolution esophageal manometry remains essential in assessing achalasia subtypes.

Gastroesophageal reflux disease-related symptom recurrence in patients discontinuing proton pump inhibitors for Bravo® wireless esophageal pH monitoring study. / Recurrencia sintomática relacionada con la enfermedad por reflujo gastroesofágico en pacientes que descontinúan los inhibidores de la bomba de protones durante el estudio inalámbrico de monitorización de pH esofágico Bravo®.

BACKGROUND: Patients with gastroesophageal reflux disease (GERD) are treated with proton pump inhibitors (PPIs). Those that do not achieve symptom relief, or non-responders, usually undergo esophageal pH monitoring off PPIs in order to confirm the presence of GERD. AIMS: To assess the efficacy of the reverse-PPI trial in evaluating the presence of GERD or its recurrence rates, as well as to identify a correlation between the symptom recurrence rates and GERD severity determined by 48-hour Bravo® esophageal pH-monitor testing. METHODS: A final total of 205 patients that underwent the 48-hour Bravo® esophageal pH-monitoring study were retrospectively included. Patients discontinued PPI usage for at least 7 days prior to testing, and completed symptom questionnaires during the 2-day test. The Bravo® test was considered positive if the percentage of time with esophageal pH <4 was >4.4%. RESULTS: A total of 363 patients underwent 48-hour Bravo® testing and of those patients, 205 were eligible for the study. Ninety-two patients reported symptoms as being «same/better¼ and 113 as being «worse¼ after stopping PPIs. Of the 92 patients with improved symptoms, 44 (48%) had documented acid reflux during the Bravo® study, compared with 65 of 113 (58%) patients with worsening symptoms that also complained of acid reflux. Of the 109 patients found to have confirmed GERD upon pH monitoring, 65 (59.6%) reported a worsening of symptoms, compared with 48 of 96 (50.0%) patients without GERD (p=0.043). Main symptoms stated to be worse included heartburn, chest pain, regurgitation, nausea, and belching (p<0.05). Of the 205 patients, 103 were off PPIs for 7 days. Seventy-two of them (68.9%) reported a worsening of symptoms, compared with 40 of the 102 (41.2%) patients that were off PPIs for>7 days (p=0.042) CONCLUSION: Symptom exacerbation following PPI cessation for at least 7 days correlated with acid reflux severity assessed by Bravo® testing. Patients off PPIs for 7 days had a higher likelihood of experiencing worsening symptoms, compared with those off PPIs for more than 7 days. These findings suggest that when PPIs are held for 7 days or less prior to Bravo® testing, acute worsening of upper GI symptoms due to the abrupt discontinuation of therapy may influence the Bravo® results. The etiology of this may be related to rebound acid hypersecretion and needs to be further elucidated in future studies.

Pathogenesis and outcomes of traumatic injuries of the esophagus.

Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross-sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98-3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65-5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50-4.71]) and male gender (OR = 1.52 [1.46-1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07-1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39-1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (∼46%) and mortality (∼20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.