Overweight Patterns Between Childhood and Early Adulthood and Esophageal and Gastric Cardia Adenocarcinoma Risk.

OBJECTIVE: Esophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) are among the most rapidly increasing cancers in Western countries. Elevated BMI in adulthood is a known risk factor, but associations in early life are unclear. METHODS: This study assessed weight change between childhood and early adulthood in relation to EA/GCA. Measured weights and heights during childhood (7-13 years) and early adulthood (17-26 years) were available for 64,695 young men from the Copenhagen School Health Records Register and the Danish Conscription Database. Individuals were categorized as having normal weight or overweight. Linkage with the Danish Cancer Registry identified 275 EA/GCA cases. Hazard ratios (HR) and 95% CI were estimated using Cox proportional hazards regression. RESULTS: The risk of EA/GCA was 2.5 times higher in men who were first classified as having overweight at age 7 (HR = 2.49; 95% CI: 1.50-4.14) compared with men who were never classified as having overweight. Men who had persistent overweight at ages 7 and 13 and in early adulthood had an EA/GCA risk that was 3.2 times higher (HR = 3.18; 95% CI: 1.57-6.44). However, there was little evidence of increased EA/GCA risk for men with overweight during childhood and subsequent remittance by early adulthood. CONCLUSIONS: Persistent overweight in early life is associated with increased EA/GCA risk, which declines if body weight is reduced.

Infantile Achalasia Cardia.

BACKGROUND: Achalasia is extremely rare in infants. CASE CHARACTERISTICS: We report three infants of age 9, 7 and 12 months, who presented with recurrent non-bilious vomiting, repeated chest infection and severe failure to thrive. Diagnosis of achalasia cardia was confirmed on contrast-swallow study. Hellers cardiomyotomy with fundoplication led to complete symptomatic relief, and weight-gain on follow-up. MESSAGE: Achalasia cardia is often misdiagnosed as gastroesophageal reflux disease which leads to significant delay in diagnosis and increased morbidity.

[Efficacy and safety of peroral endoscopic myotomy in the treatment of achalasia cardia].

OBJECTIVE: To evaluate the efficacy and safety of peroral endoscopic myotomy (POEM) for achalasia cardia (AC).
 METHODS: A total of 62 patients with AC were enrolled and treated with POEM in the Third Xiangya Hospital, Central South University from April 2012 to October 2014. The symptoms and complications were retrospectively analyzed.
 RESULTS: The ages of patients, including 32 males and 30 females, were 14-68 (43.2±5.6) years old. Eckardt scores were 4-6 or ≥7 for 25 patients or 37 patients (including 20 patients were at a score of 12). Thirteen patients suffered balloon expansion for 2-3 times. Sixty-one patients had completed POEM treatment, 1 patient were given Heller surgery instead of POEM because of extensive submucosal adhesion during POEM. The operative time for POEM was (60.8±15.1) min. Fourteen patients had mild subcutaneous emphysema. Among them, 5 suffered pneumoperitoneum and felt better after abdominal puncture exhaust; 2 patients suffered bronchospasm hypoxemia and were relieved after treatment by positive pressure oxygen for 1 h. The hospital stay was (4.3±1.2) d. The postoperative follow-up period was (11.4±5.4) months. Swallowing obstruction, vomiting and chest pain in patients was relieved at different degrees. The treatment effective rate was 100%. 
 CONCLUSION: POEM is a safe, effective and minimally invasive approach for AC.

[Diagnosis and treatment of achalasia cardiae].

Achalasia is a progressive oesophageal motility disorder of unstudied aetiology involving the smooth muscle layer of the oesophagus. Insufficient knowledge of the pathogenesis of achalasia and the lack of clear treatment approaches has led to an increase of advanced disease forms. Common clinical manifestations of the disease are: incomplete LES relaxation, non-specific initial manifestations and as a result late medical seeking. Occurrence of achalasia cardiae is significantly low, therefore it is important to analyse the available clinical data. The article presents an experience of treatment of 30 patients over the last 16 years of observation. The average age of patients was 50, 5 years; insignificant male predominance is noted. III or IV disease state was diagnosed in 86.7% of patients; this diagnosis was confirmed by esophagogastroduodenoscopy. In the group of 24 patients who underwent attempted endoscopic dilatation of the cardiae, most of the included patients with stage II and III disease. Immediate good and satisfactory results of endoscopic treatment were obtained in 20 patients (83.3%), in 4 cases (16.7%) developed recurrent disease.

Pneumatic dilation for achalasia cardia: reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow up.

BACKGROUND: Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty. METHODS: Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated. RESULTS: Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4-75], 11 mmHg [4.6-31]vs 25 mmHg [13-55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure <10 mmHg after the procedure recurred less often, although there was no relationship with age and gender. CONCLUSION: Post-PD LES pressure measurement is useful to assess treatment response. Patients responding to the first session and those with post-PD LES pressure <10 mmHg tended to recur less. Age and gender did not influence outcome, which might be related to preferential use of a 35-mm balloon, particularly for male patients, during the first session.

Achalasia cardia with esophageal varix managed with endoscopic ultrasound-guided botulinum toxin injection.

Achalasia cardia is a motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter. Nitrates and calcium channel blockers, pneumatic dilatation, botulinum toxin injection and surgical myotomy have been described in literature as possible management options. We present a patient who presented with achalasia and was co-incidentally diagnosed to have cryptogenic cirrhosis with portal hypertension and had esophageal varices. This clinical combination precluded the use of pneumatic dilatation and surgical myotomy. We injected botulinum toxin into the lower esophageal sphincter using a celiac plexus neurolysis needle under endoscopic ultrasound guidance; the clinical response was good.

[Peroral endoscopic myotomy for esophageal achalasia: report of 42 cases].

OBJECTIVE: To evaluate the efficacy and the feasibility of peroral endoscopic myotomy (POEM) for esophageal achalasia (AC). METHODS: The clinical data of 42 patients diagnosed as AC and received POEM in the Zhongshan Hospital of Fudan University between August 2010 and March 2011 were reviewed retrospectively. The key procedures of POEM included esophageal mucosal incision, submucosal "tunneling" by endoscopic submucosal dissection(ESD) technique, endoscopic myotomy of the circular muscle, and closure of mucosal incision by hemostatic clips. RESULTS: The mean age of 42 cases was 43.9(range 10-70) years. The mean duration of disease was 8.7 years (range, 3 months to 50 years). The mean operative time was (68.5 ± 25.5) (range 23-180) minutes with a mean submucosal tunneling length of(10.5 ± 1.5)(range 8-15) cm. The average length of endoscopic myotomy of inner circular muscle was(9.5 ± 2.5)(range 7-13) cm. No serious complications related to POEM were encountered. The median follow-up period was 2.5(range 1-6) months. Dysphagia symptom was relieved significantly during the follow-up period in 41 patients; one patient had dysphagia and vomiting 15 days after the operation. Endoscopic observation showed a submucosal fistula which was managed by endoscopic incision. CONCLUSIONS: As a novel minimally invasive therapy for AC, POEM appears to have definite short-term outcomes and can rapidly alleviate dysphagia symptom. Further observations and long follow-up are needed to evaluate long-term outcome and complications.

Efficacy of Rikkunshito, a traditional Japanese medicine (Kampo), in treating functional dyspepsia.

BACKGROUND: Rikkunshito, a traditional Japanese (Kampo) medicine, is widely prescribed as an oral preparation for the treatment of functional dyspepsia (FD). In our previous study, we reported that extracorporeal ultrasonography (US) is a useful technique for the assessment of the gastric accommodation reflex (AR) and duodenogastric motility. In this study, we examined the effects of Rikkunshito on the gastroduodenal function in patients with FD. METHODS: Sixteen FD patients (median age, 45 y) underwent US, before and after 14 days of treatment with Rikkunshito (7.5 g b.d.). For assessment of the AR, a cross-sectional area of the proximal stomach was measured after incremental ingestion of a liquid meal up to 400-mL. The expansion rate was used as the parameter to determine the AR. Then, the gastric emptying rate (GER), motility index (MI), and reflux index (RI) were evaluated using previously reported methods. RESULTS: Although no significant changes were observed in the total score of the Gastrointestinal Symptom Rating Scale (GSRS), the scores of 3 of the 15 symptoms of GSRS decreased significantly after treatment with Rikkunshito. The expansion rate of the proximal stomach was significantly greater after treatment with Rikkunshito than before the treatment. Although the GER and MI increased significantly, no significant differences in the RI were observed after treatment with Rikkunshito. CONCLUSION: These observations suggested that Rikkunshito may be beneficial for the treatment of FD patients with impaired AR and gastric motility. These results also suggested that Rikkunshito has a therapeutic potential for FD and GERD.

Megaesófago en un paciente con acalasia avanzada / No disponible

No disponible

[Long-term results of esophageal motor dysmotility after Heller's myotomy for achalasia].

OBJECTIVE: To investigate the long-term characteristics of both clinical manifestation and esophageal motor disturbance in achalasia patients after Heller's myotomy. METHODS: After 3 to 10 years' follow-up, clinical manifestation, esophageal motor function and 24-hour continuous esophageal pH monitoring in 72 post-operative cases of achalasia were recorded. RESULTS: The mean LES pressure decreased from 44 + or - 12 mm Hg to 10 + or - 5 mm Hg, and the rate of L ES relaxation rised from 49% + or - 20% to 84% + or - 15% (paired t test, P < 0.05). Of 24 cases with choking feeling, 11 had the high LES pressure and dysfunction in two directions and 7 in three. During swallowing, incomplete lower esophageal sphincter relaxation and aperistalsis were detected in all patients. CONCLUSIONS: The long-term characteristics of esophageal function following successfully surgical treatment to patients with Achalasia are: (1) After Heller's myotomy, LESP in at least one direction is lower than the normal standard, while higher in at least one direction. (2) During swallowing, the esophageal rear wall is lack of complete LES relaxation. For patients with choking feeling, complete LES relaxation occurs in 2-3 directions. (3) Due to lack of esophageal peristalsis, food goes through esophagus by gravitation.

[Experience of reconstructive operations on the cardioesophageal passage].

Description of a clinical case of cardiac achalasia unclear in step of diagnostics in consequence of inferiority examination that has brought about vain fundoplication caused constant and expressed breach of the food passage through cardioesofageal junction.

Evaluating outcomes of endoscopic full-thickness plication for gastroesophageal reflux disease (GERD) with impedance monitoring.

BACKGROUND: Endoscopic full-thickness plication allows transmural suturing at the gastroesophageal junction to recreate the antireflux barrier. Multichannel intraluminal impedance monitoring (MII) can be used to detect nonacid or weakly acidic reflux, acidic swallows, and esophageal clearance time. This study used MII to evaluate the outcome of endoscopic full-thickness plication. METHODS: In this study, 12 subsequent patients requiring maintenance proton pump inhibitor therapy underwent endoscopic full-thickness plication for treatment of gastroesophageal reflux disease. With patients off medication, MII was performed before and 6-months after endoscopic full-thickness plication. RESULTS: The total median number of reflux episodes was significantly reduced from 105 to 64 (p = 0.016). The median number of acid reflux episodes decreased from 73 to 43 (p = 0.016). Nonacid reflux episodes decreased from 23 to 21 (p = 0.306). The median bolus clearance time was 12 s before treatment and 11 s at 6 months (p = 0.798). The median acid exposure time was reduced from 6.8% to 3.4% (p = 0.008), and the DeMeester scores were reduced from 19 to 12 (p = 0.008). CONCLUSION: Endoscopic full-thickness plication significantly reduced total reflux episodes, acid reflux episodes, and total reflux exposure time. The DeMeester scores and total acid exposure time for the distal esophagus were significantly improved. No significant changes in nonacid reflux episodes and median bolus clearance time were encountered.

Relationship of the frequency scale for symptoms of gastroesophageal reflux disease with endoscopic findings of cardiac sphincter morphology.

BACKGROUND: Kusano et al. developed a questionnaire for the evaluation of gastroesophageal reflux disease (GERD), the frequency scale for the symptoms of GERD (FSSG). The FSSG is now widely used in Japan. We investigated the relationship between FSSG results and cardiac sphincter endoscopic findings. METHODS: The subjects were 470 patients who responded to the FSSG before undergoing endoscopy. From the FSSG results, we calculated the total, acid reflux, and dysmotility scores. Endoscopic findings were assessed in terms of the anatomic-functional-pathological (AFP) classification as the A factor, or degree and type of hiatal hernia, and the valve factor, or laxity of the cardiac sphincter. The degree of esophagitis was assessed using the modified Los Angeles classification. We investigated correlations between each score and the anatomy of the cardia. RESULTS: With either definition of esophagitis (grade M or greater, or grade A or greater), the total and acid reflux scores were both significantly higher in the group with reflux esophagitis than in the group without reflux esophagitis. Examination of the relationship between FSSG scores and the A factor revealed no significant differences in the total, acid reflux, or dysmotility scores whether a hiatal hernia was present or absent. Similarly, examination of the valve factor showed no significant difference in any scores between V0 and V1 versus V1 and V2, indicating no correlation between cardiac sphincter laxity and FSSG scores. CONCLUSIONS: The FSSG was useful in determining whether reflux esophagitis is present, but it did not predict the anatomy of the cardia.

The integrity of esophagogastric junction anatomy in patients with isolated laryngopharyngeal reflux symptoms.

BACKGROUND: Distortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms. METHOD: In a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett's esophagus within each group. RESULTS: There were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett's esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett's esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology. CONCLUSION: This indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett's esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer.

[Functional changes in the cardioesophageal region following laparoscopic fundoplication]. / Funkcni zmeny kardioezofageální oblasti po laparoskopické fundoplikaci.

UNLABELLED: Functional changes of antireflux mechanisms after laparoscopic fundpolication. AIM: To examine manometry and pH-study in evaluation of the changes in measurable features of antireflux mechanisms after fundoplication for gastro-oesophageal reflux disease. METHODS: Laparoscopic Nissen-Rossetti fundoplications with hiatorhaphy were performed in patients with gastroesophageal reflux disease. Preoperative and postoperative manometry and pH-study were compared in set of twenty satisfied orjerated without any complaints after surgery who agreed with preoperative and postoperative examinations. RESULTS: Higher length of lower esophageal sphincter following antireflux fundoplication (P = 0.0003), increased tone of lower esophageal sphincter with antireflux fundoplication (P = 0.0001) and lower value of pH-study after fundoplication (P = 0.0001) were observed. CONCLUSION: Postoperative manometry and pH-study effectively evaluated gastro-oesophageal reflux changes following fundoplication for gastro-oesophageal reflux disease.

Gastric carditis: Is it a histological response to high concentrations of luminal nitric oxide?

During the last decade, inflammation (carditis) and intestinal metaplasia localized to immediately below the human gastro-oesophageal junction have received much attention in relation to the rising incidence of cancer at this site. Since these histological findings are frequently observed even among those who are H pylori-negative, the causative factors for such histologic events at the human gastro-oesophageal junction remain obscure. A series of recent studies have demonstrated that a high level of salivary nitrite is sustained over several hours after the ingestion of a high nitrate meal, and that the nitrite in swallowed saliva is rapidly converted to nitric oxide by an acid catalyzed chemical reaction at the gastro-oesophageal junction. Eventually, a substantial amount of nitric oxide diffuses from the lumen into the adjacent tissue. Therefore, the human gastro-oesophageal junction is likely to be a region of high nitrosative stress. Considering the life-time exposure of the gastro-oesophageal junction to cytotoxic levels of nitric oxide, this may account for the high prevalence of inflammation, intestinal metaplasia, and subsequent development of neoplasia at this site. Although gastric acid, pepsin, and bile acid have been intensively investigated as a cause of adenocarcinoma at the gastro-oesophageal junction and the distal esophagus, nitric oxide and the related nitrosative stress should also be examined.

[Surgical treatment of stage IV cardial achalasia].

An original method of surgical treatment of patients with stage IV cardial achalasia was developed. Seven patients aged 42 to 59 years underwent surgery according this method. Objective methods of examination and life quality study with GIQLI carried out 3 months to 5 years after surgery demonstrate satisfactory anatomic and functional results.