[Diffuse esophageal spasm (DES). Practical concepts of diagnosis and treatment]. / El espasmo esofágico difuso (EED). Conceptos prácticos sobre diagnóstico y tratamiento.

Diffuse esophageal spasm (DES) is a motility disorder of undetermined etiology, typically presenting with chest pain, dysphagia or both. The aim of this paper is to provide a critical review of the prevalence, pathogenesis, diagnosis and therapy of DES. Data from referral centers indicates that this is a rare disorder with a prevalence of 4-7%. The diagnosis is based on the combination of typical symptoms, radiological findings and manometry (simultaneous contractions (SC) in the distal esophagus in > or = 20% of wet swallows mixed with normal peristalsis). The pathogenesis remains poorly understood. Recent evidence suggests that nitric oxide deficiency may explain the SC that characterizes this condition at manometry. Gastroesophageal reflux (GER) can coexist in DES and GER has also been implied in the pathogenesis of DES. Whether patients with DES and GER represent a subtype of DES with a different prognosis or outcome is unknown. We present a critical appraisal regarding different therapeutic approaches available for DES and conclude suggesting a management algorithm based on current available literature.

[Usefulness of botulinum toxin in gastrointestinal disorders]. / Utilidad de la toxina botulínica en los trastornos gastrointestinales.

Botulinum toxin (Botox) produced by Clostridium botulinum is a potent neuromuscular blocker agent that inhibits acetylcholine release from presynaptic nerve endings. This effect was confirmed in the smooth muscle of the gastrointestinal tract and led to clinical trials investigating the efficacy of Botox for treatment of several gastrointestinal disorders. Multiple controlled studies have shown that Botox is effective in short-term management of achalasia. Botox reduces lower esophageal sphincter pressure, improves esophageal clearance, and alleviates symptoms in up to 70% of patients; however, its long-term efficacy decreases to 30% and repeated injections are often necessary. Botox is reserved for older patients and with high surgical risk. The main predictors of a good response are older age and presence of vigorous achalasia. Biliary or pancreatic sphincter of Oddi dysfunction (SOD) has been another indication for Botox administration. Transendoscopic injection of Botox in the papilla of Vater has shown relief of symptoms in more than 50% of cases of SOD. Furthermore, a Botox clinical response in this condition can predict a long-term benefit with endoscopic sphincterotomy. Botox decreases resting anal pressure, has healing rates of approximately 80% at six months after injection in patients with chronic anal fissure, and has a better outcome than topic nitroglycerine. Case reports have shown good results with Botox administration in treatment of diffuse esophageal spasm, anismus, oropharyngeal dysphagia, anterior rectocele, and secondary achalasia. Administration of botulinum toxin has a low rate of adverse reactions and complications.

Trastornos de motilidad esofágica / Disturbances of esophageal motility

Se describe las características de los trastornos motores esofágicos más frecuentes. Es importante pensar en estos cuadros frente a dolores torácicos de causa no cardíaca. De éstos el más común parece ser el esófago en cascanueces. Se analiza la fisiopatología, clínica, diagnóstico y tratamiento de los principales, haciendo énfasis especial en el tratamiento quirúrgico, el que con el advenimiento de la laparoscopia, representa una buena alternativa frente al tratamiento médico convencional, de tan pobres resultados

[Motor disorders of the smooth muscle of the esophagus]. / Trastornos motores del músculo liso del esófago.

Dysphagia and/or chest pain are the symptoms that characterize the motor abnormalities of the esophagus. These symptoms are not specific for motor disorders and can be seen with mucosal lesions. Symptom varies in severity and can be severe enough to put in risk the patient life. Motor dysfunction of the esophagus can be idiopathic, when it is not related to another systemic disease, or secondary, when it is associated to a generalized disease. Diagnosis and characterization of the motor disorders of the esophagus are best performed by manometry. In the present work, we expose some of the relevant clinical aspects and the manometric criteria currently accepted to classify motility disorders. Some treatment aspects are also reviewed.