Effect of dilatation of peptic esophageal strictures on gastroesophageal reflux,dysphagia, and stricture diameter

In 10 patients with peptic esophageal stricture the effect of esophageal dilatation on intraesophageal pH, stricture diameter, and dysphagia has been studied. Percentage of time during which intraesophageal pH was <4 and the number of reflux episodes per hour did not change significantly. Stricture diameter increased slightly, but consistently, from 7.0±0.5 mm to 9.1±0.5 mm (P <0.01) four days after dilatation, but was not significantly different from predilatation values after 12 weeks. Improvement in symptoms of dysphagia was striking ( P <0.01) four days and six weeks after dilatation, but worsened again at 12 weeks (P=NS). It is unlikely that esophageal dilatation adversely affects the intraesophageal environment.     

Syncope induced by propranolol in hypertrophic cardiomyopathy

A patient with chest pain was found to have obstructive hypertrophic cardiomyopathy. After the first oral dose of propranolol, syncope developed together with atrioventricular block. An electrophysiologic study revealed an intermittent advanced (His-Purkinje) block within the atrioventricular conduction system. Caution is recommended when treatment is initiated in patients with hypertrophic cardiomyopathy in whom there is any suspicion of abnormalities in the atrioventricular conduction tissues.     

Brain abscess following esophageal dilatation

The authors report a case of brain abscess following esophageal dilatation for corrosive stricture in a 23-year-old woman. High fever and neurological findings post dilatation led us to suspect this rare complication, which was confirmed by cranial computed tomography. Prompt treatment with antibiotics and surgical drainage led to a favorable clinical outcome. This serious complication should be kept in mind when long-term treatment of corrosive stricture by repeated esophageal dilatation is planned. Prior cases of brain abscess following esophageal dilatation are reviewed.     

Manometric findings in dysphagia secondary to left atrial dilatation

Summary A 26-year-old male with left atrial dilatation because of severe mitral stenosis presented with dysphagia and weight loss. Esophagogastroduodenoscopy revealed transmitted mural pulsations occurring at the frequency of the peripheral pulse and a compressed lumen in the midesophagus. Esophageal manometry revealed in the midesophagus a high-pressure zone with normally transmitted peristaltic waves through this region. Superimposed on the elevated baseline pressure in this zone were cyclic pressure waves occurring one-for-one with the QRS complex of the electrocardiogram. The midesophageal high-pressure zone and cyclic pressure waves are explained by pulsatile compression by the left atrium. Proximal and distal to this zone, the baseline esophageal pressure was normal, with no pressure oscillations present. This is the first direct manometric evidence that this dysphagia is due to mechanical obstruction from extrinsic compression and not due to dysmotility from esophageal nerve compression and injury by the dilated left atrium. This mechanism was previously supported by indirect radiographic evidence.     

The endoscopic treatment of benign esophageal strictures by balloon dilatation

Benign strictures of the esophagus are serious illnesses that have a great adverse effect on the quality of life of patients. There are several methods of treatment. In this study the endoscopical balloon dilatation technique was used. All dilatations were performed under analgosedation, and plastic balloons (6-25 mm) were used. Ninety dilatations were performed between 1995 and 1997. Twenty-two patients were diagnosed as having benign stenosis of the esophagus. We evaluated the effectiveness and the complication rate of the method. All patients except two showed immediate improvement: 59% were cured; 18% had at least one recurrence of the stenosis; 9% had improvement but treatment continues; 14% required other treatment. We encountered two cases with major complications, i.e. perforation. Balloon dilatation seems to be an effective and safe method for treatment of the benign esophageal strictures and is well tolerated by patients. Endoscopic control is sufficient, and radiographic control is not required. Randomized prospective studies are needed to establish the role of this method in comparison with other treatments.     

The physics of esophageal dilatation.

The use of dilators to enlarge esophageal strictures is an old and widely used technique. New technology and designs permit reduced trauma and complications and may ultimately extend the durability of the procedure. Understanding the physics of dilators and their use is essential for clinicians to achieve maximum therapeutic benefit for their patients.     

Pneumatic dilatation of lower esophageal ring

Six patients with symptomatic lower esophageal ring were studied by cine-fluorography and then treated by pneumatic dilatation of the esophagus. All experienced relief of dysphagia and have been followed for 3 years without recurrence of symptoms. It is concluded that pneumatic dilatation of symptomatic lower esophageal ring is the treatment of choice and offers prolonged beneficial results, making surgical correction unnecessary.Former Chief of Gastroenterology, Keesler Air Force Base, Biloxi, Miss; now Chief of Gastroenterology, Veterans Administration Hospital, Phoenix, Az     

Syncope induced by tobacco smoking in the head-up position.

A 26-year-old man had a loss consciousness for a few minutes while smoking in the standing position, and was referred to hospital. No abnormalities were found in a computed tomography examination of his head, in a 24-h electrocardiogram or in an exercise tolerance test. The head-up tilt test (HUT) while tobacco smoking elicited a positive response in the tilted position, but the HUT without tobacco smoking was negative. The most noteworthy effect of tobacco smoking during the HUT was the high level of plasma epinephrine compared to the levels seen during supine smoking or the HUT alone. Syncope induced by tobacco smoking in the standing position is rare and the mechanism may be the same as that underlying neurally mediated syncope.     

Unexplained dysphagia: Viscous swallow-induced esophageal dysmotility

Dysphagia is a manifestation of several clinical conditions of diverse origin. In spite of the variation in these disease entities in terms of their etiology, clinical presentation, natural history, and treatment, the mechanism of this clinical complaint is not always clear. We studied a group of patients with dysphagia for solids in whom no anatomic or motor abnormalities were encountered on standard studies. The group consisted of 37 patients, 25 women and 12 men, who were complaining of dysphagia of 6 months or longer duration and they did not demonstrate structural or motor abnormalities on barium esophagogram, esophagoscopy, and standard esophageal manometry. A group of 24 age-matched patients, 14 women and 10 men, with noncardiac chest pain served as the patient control. Esophageal contractile activities were studied after 10 wet swallows (5 ml of water) and 10 viscous swallows (5 cubic cm of marshmallow). Resting lower esophageal sphincter pressure and its relaxation response to swallows, amplitude of peristaltic activities, rate of dysphagia provoked during the study, and the frequency of abnormal esophageal contractions were evaluated. Six abnormal esophageal contractile activities—failed peristalsis, dropout, repetitive, simultaneous, spontaneous contractions, and aperistalsis—were utilized to generate an esophageal peristaltic dysfunction index. The mean LESP was 8.1±4.7 in the dysphagia group and 16.1±4.3 in the chest pain group. The mean amplitude of peristaltic contractions was 47.1±16.1 and 89.0±27.0 mmHg after wet swallows for dysphagia and chest pain groups, respectively. These values were 58.2±12.4 and 92.4±22.1 for viscous swallows. Swallowing provoked dysphagia in 89% of the dysphagia group after viscous swallows and 9% after wet swallows. In contrast, only 11% and 3% of control group complained of dysphagia during the study. This group of patients probably represent a cohort of patients with a nonspecific esophageal motor disorder in whom both clinical symptom and their esophageal motor counterpart can only be elicited in response to viscous swallows. We strongly believe in addition of viscous swallows in evaluating dysphagic patients in whom symptoms remain unexplained in light of standard studies.