An Unusual Case of Dysphagia: Esophageal Intramural Pseudodiverticulosis

A 30-yr-old man presented with chronic dysphagia and a questionable upper gastrointestinal hemorrhage. On endoscopic evaluation, numerous openings were seen throughout the esophagus. Barium esophagram confirmed the diagnosis of esophageal intramural pseudodiverticulosis. The clinical presentation and the endoscopic, radiographic, histopathological, and manometric data are presented. Our findings illustrate common esophageal conditions associated with this rare entity.     

Patient Localization of Esophageal Dysphagia

The accuracy of patients' symptom localization in dysphagia is not clear. This study aims to determine the accuracy of patient localization and to determine the correlation of localization with motility disorders. We reviewed 100 patients after completion of EGD, manometry, and a dysphagia questionnaire. Proximal and midesophageal localization were rarely associated with a proximal cause of dysphagia. Distal localization correlated in 80% of cases. Fifty-seven percent of patients reporting diffuse symptoms had manometric abnormalities, but only 9% of patients with manometric abnormalities reported diffuse symptoms. In conclusion, patient localization in esophageal dysphagia is not accurate. The data suggest that proximal localization is especially inaccurate, whereas distal localization may be more accurate. Finally, there is no correlation between diffuse localization and diagnosis of motility disorders.     

非梗阻性食管源性吞咽困难患者食管测压结果分析

背景:食管源性吞咽困难的病因可分为机械性梗阻和动力障碍两类。目前关于致吞咽困难的食管动力障碍类型的研究相对较少。目的:分析非梗阻性食管源性吞咽困难患者的食管测压结果,探讨引起吞咽困难症状的常见食管动力障碍类型。方法:纳入2007年1月～2012年6月西安交通大学医学院第二附属医院50例以吞咽困难为主诉而行食管测压者,对其测压结果进行分析。入组患者通过病史询问、内镜或食管钡透检查等除外非食管源性和梗阻性吞咽困难。结果:36例(72.0%)患者的食管动力障碍类型为非特异性食管动力障碍(NEMD),13例(26.0%)为贲门失弛缓症,1例(2.0%)食管测压结果正常。9例(18.0%)合并胃食管反流病者均为NEMD。NEMD和贲门失弛缓症患者的食管动力障碍均以食管体部运动功能紊乱和下食管括约肌功能异常为主。结论:本组非梗阻性食管源性吞咽困难患者的食管动力障碍类型多为NEMD,其次为贲门失弛缓症。非梗阻性食管源性吞咽困难患者的食管测压结果可能正常。     

Comparison of Esophageal Motility in Patients with Solid Dysphagia and Mixed Dysphagia

It is unclear whether there is any difference in esophageal motor abnormalities between patients complaining of dysphagia for solids or both solids and liquids. The aim of this study was to determine any difference in the manometric findings between patients with dysphagia for solids and those with mixed dysphagia. Manometric tracings were performed in 200 consecutive patients (66M, 134F; mean age = 51 years) with nonobstructive dysphagia. Ambulatory pH studies were performed in all patients. Subjects were divided into two groups: patients with solid dysphagia (n = 94, 33M, 61 F; mean age = 51 years) and those with mixed dysphagia (n = 106, 33M, 73F; mean age = 51 years). A normal motility study was the most frequent finding. Achalasia occurred more frequently in patients with mixed dysphagia than in those with solid dysphagia (12% vs. 3%, p < 0.01). Gastroesophageal reflux disease (GERD) was observed in 59% of patients with solid dysphagia compared with 29% of patients with mixed dysphagia (p < 0.02). The most common esophageal motility abnormality is nonspecific esophageal motility disorders. This study has shown that abnormal esophageal motility occurs slightly more in mixed dysphagia than solid dysphagia. The clinical utility of a symptomatic differentiation of patients with solid or mixed dyphagia appears to be limited.     

Irreversible Esophageal Motor Dysfunction in Postvagotomy Dysphagia

Postvagotomy dysphagia is typically a temporary phenomenon but a small subgroup of patients appear to develop irreversible motility disorders of the esophagus. Two patients are reported with persistent symptomatic esophageal dysfunction demonstrated by modern hydraulic infusion technics. Both intially lost weight rapidly and then stabilized. The distal esophagus of both was greatly dilated but in one patient, lower esophageal sphincter pressure was normal. Aperistalsis with diminished motor activity was present throughout the body of the esophagus. Dysphagia and objective esophageal abnormalities were refractory to dilations with simple mercury bougies in one patient whose condition was improved by treatment with pneumatic dilation. The cause of this unusual complication is unknown but may involve a nonneoplastic form of secondary achalasia.     

Esophageal Peristaltic Defects in Adults with Functional Dysphagia

Functional dysphagia (FD) is characterized by the presence of dysphagia without evidence of mechanical esophageal obstruction, GERD, and histopathology-based esophageal motor disorders. Dysphagia is common in older patients; however, there is a paucity of information regarding the type and frequency of peristaltic abnormalities compared to younger patients. Based on recently validated criteria for classification of weak peristalsis using high-resolution manometry (HRM), we hypothesized that older patients with FD would have more peristaltic defects detected by HRM compared to younger FD patients. A retrospective review of our motility database yielded 65 patients that met inclusion criteria. Patients were divided into two groups based on age (younger: <70 years; older: ≥70 years). Patients were interviewed, completed a quality-of-life questionnaire, and underwent solid-state HRM. The two groups differed in age but in no other demographic characteristics, severity of dysphagia, or quality of life. Dyspeptic symptoms, including nausea (p < 0.001), early satiety (p = 0.01), bloating (p = 0.02), and belching (p = 0.01), were also more prevalent in younger FD patients. Older age was associated with weak peristalsis involving frequent failed peristalsis, small proximal peristaltic defects (2–5 cm), and large proximal peristaltic defects (>5 cm) (p < 0.001). The mean contraction amplitude was also lower in the older group (p < 0.05). These data support the hypothesis that older patients with FD have a higher frequency of peristaltic abnormalities on HRM compared to younger patients. Older age was associated with increased frequency of weak peristalsis with small and large peristaltic defects.