Dysphagia following fundoplication: "slipped" fundoplication versus achalasia complicated by fundoplication

Failure to obtain preoperative esophageal manometry in patients being considered for antireflux surgery can result in immediate persistent postoperative dysphagia due to a missed diagnosis of achalasia. We describe the clinical assessment and management of a case of delayed postoperative dysphagia due to a "slipped" fundoplication, which is contrasted with three patients with immediate postoperative dysphagia due to a missed diagnosis of achalasia. Surgical revision was required to correct the "slipped" fundoplication, and pneumatic dilatation was successfully used in two of three cases of achalasia complicated by fundoplication. Careful preoperative esophageal evaluation with manometry is essential to rule out the presence of a primary esophageal motor disorder.     

Vigorous achalasia in Chagas'' disease

The study investigated the esophageal motility of 98 patients with Chagas' disease and 40 asymptomatic volunteers, with the objective of comparing patients with vigorous achalasia (distal amplitude contractions >/= 37 mmHg) and patients with classical achalasia (amplitude < 37 mmHg). The Chagas' disease patients had normal esophageal radiologic transit (n=60) or esophageal slow transit and retention without dilation (n=38). The manometric method with continuous perfusion was used to study esophageal motility. Comparison of classical and vigorous achalasia showed no difference in duration of contractions, lower and upper esophageal sphincter pressure, proportion of patients with dysphagia, or the number of multipeaked contractions. The number of failed contractions was higher in patients with classic achalasia than in patients with vigorous achalasia. We conclude that the distinction between classical and vigorous achalasia does not seem to be important for the classification of Chagas' disease.     

Differential diagnosis of esophageal motor disorders based in characteristics of dysphagia

BACKGROUND: Dysphagia is one of principal symptoms of esophageal disorders and its characterization is important for diagnosis and management of patients. Anamnesis is useful for differentiating organic and functional dysphagia, but data are lacking about dysphagia characterization among different motor disorders. OBJECTIVES: To evaluate if it is possible the distinction among esophageal motor disorders according to their manometric diagnosis, based on dysphagia characteristics. PATIENTS AND METHODS: Dysphagia characteristics (relation with bolus, frequency and localization) of 133 patients submitted to esophageal manometry were reviewed and analysed. All patients had barium swallow studies and/or endoscopy in order to exclude organic lesions. RESULTS: Esophageal manometry was abnormal in 85% of the patients. Characteristics of dysphagia were compared among groups of patients with achalasia, esophageal spastic disorders, non-specific esophageal motor disorders and with normal test. The precise distinction among groups based solely on characteristics of dysphagia was not possible, however some aspects could point to one or another group. In achalasia patients, dysphagia for both solid food and liquids, constant and felt in substernal area, was more frequent in relation to every other group. Intermittent dysphagia was more frequent in patients with spastic disorders. Characteristics of dysphagia in patients with non-specific esophageal motor disorders were similar to those observed in the group with normal test, frequently referred in the neck. CONCLUSION: Characteristics of dysphagia were ancillary to presume the diagnosis of these motor disturbances, however esophageal manometry is necessary for the correct diagnosis in patients with functional dysphagia.     

Cholangiocarcinoma presenting with severe gastroparesis and pseudoachalasia.

Tumor-associated gastroparesis, though reported in association with various malignancies, is rare in patients with cholangiocarcinoma. We report a 55-year-old woman who presented with dysphagia and recurrent vomiting. Esophagogastroduodenoscopy revealed dilated stomach and excess residue without organic obstruction. 99mTc sulfur colloid solid gastric emptying study, radio-opaque marker gut transit study, and esophageal manometry showed features suggestive of gastroparesis and achalasia cardia; electrogastrography revealed bradygastria. Cholangiocarcinoma was detected on CT scan performed after the patient developed jaundice two months later. The lesion was deemed surgically unresectable. She died four months later.     

Effect of transcutaneous nerve stimulation on esophageal motility in patients with achalasia and scleroderma

It has been suggested that low-frequency transcutaneous electric nerve stimulation (TENS) alleviates the dysphagia produced by achalasia and scleroderma of the esophagus. The present study was conducted to elucidate whether TENS treatment improves dysphagia because of changes it induces on esophageal motility. We studied nine achalasia patients before forceful dilatation of the cardias, nine achalasia patients after dilatation, and nine patients with scleroderma. High-frequency TENS was applied to the hand for 30 min while esophageal motility was monitored by manometry. In none of the groups did TENS produce any change in the basal tone of the lower esophageal sphincter, lower esophageal sphincter relaxation, or esophageal body wave amplitude. Low-frequency TENS, used in another seven untreated achalasia patients, also did not improve esophageal motility. Our data indicate that high- or low-frequency TENS does not induce detectable changes in esophageal motility in patients with achalasia or scleroderma.     

Swallow-Induced Syncope in a Patient with Achalasia

A 48-year-old man was referred for the evaluation of dysphagia and syncope. He suffered from both dysphagia and transient loss of consciousness when eating solid food, especially bread. An upper gastrointestinal barium examination and esophageal manometry suggested achalasia. Ambulatory ECG revealed marked sinus bradycardia when experiencing a syncopal episode following the ingestion of a solid meal. A permanent pacemaker was implanted and the patient’s syncopal attacks were relieved following this procedure. However, the dysphagia and cardiac arrhythmia completely disappeared only following a successful pneumatic balloon dilatation for achalasia. This observation suggests that swallowing-induced sinus bradycardia and syncope might occur in the course of achalasia and these rhythm abnormalities could be relieved by successful treatment of the achalasia.     

Effect of Transcutaneous Nerve Stimulation on Esophageal Motility in Patients with Achalasia and Scleroderma

It has been suggested that low-frequency transcutaneous electric nerve stimulation (TENS) alleviates the dysphagia produced by achalasia and scleroderma of the esophagus. The present study was conducted to elucidate whether TENS treatment improves dysphagia because of changes it induces on esophageal motility. We studied nine achalasia patients before forceful dilatation of the cardias, nine achalasia patients after dilatation, and nine patients with scleroderma. High-frequency TENS was applied to the hand for 30min while esophageal motility was monitored by manometry. In none of the groups did TENS produce any change in the basal tone of the lower esophageal sphincter, lower esophageal sphincter relaxation, or esophageal body wave amplitude. Low-frequency TENS, used in another seven untreated achalasia patients, also did not improve esophageal motility. Our data indicate that high- or low-frequency TENS does not induce detectable changes in esophageal motility in patients with achalasia or scleroderma.     

Nonoperative management of esophageal strictures following esophagomyotomy for achalasia

The optimal management of reflux-induced esophageal strictures that occur after esophagomytomy for achalasia is uncertain. This paper presents our experience with the nonsurgical treatment of postesophagomyotomy strictures in achalasia patients using endoscopic dilation and gastric acid suppression. Six patients with achalasia who had undergone prior esophagomyotomy subsequently developed recurrent dysphagia and were found to have an esophageal stricture. Esophagrams typically showed a markedly dilated esophagus with a narrowed, sharply angulated gastroesophageal junction. Esophageal manometry confirmed esophageal aperistalsis and, when measured, the LES pressure was<5 mm Hg. Endoscopy showed esophageal inflammation and a fixed stricture at the gastroesophageal junction. Strictures were dilated under direct visualization using through-the-scope balloon dilators. Patients began gastric acid suppressive treatment at the same time. Five patients who remained symptomatic underwent repeat endoscopy, which demonstrated improvement in esophagitis. Dilation was then repeated with a larger balloon dilator. Over a mean follow-up period of 3.8 years, the average number of repeat dilations per patient was 3.6 (range: 0–12). All patients had symptomatic improvement and weight gain. No patient required surgery. We conclude that esophageal strictures after esophagomyotomy for achalasia can be safely treated using endoscopic dilation and gastric acid suppression, thus avoiding the need for reoperation.     

Apparent complete lower esophageal sphincter relaxation in achalasia

Seven of 23 patients (30%) seen in 2 yr with clinical and radiologic manifestations of achalasia underwent esophageal manometry demonstrating aperistalsis but apparent complete lower esophageal sphincter (LES) relaxation. Detailed clinical and laboratory evaluation suggests these patients may represent an early stage of achalasia. Duration of dysphagia and weight loss were significantly less (p less than 0.05), whereas LES pressure was similar in the 7 patients compared with the 16 more traditional achalasia patients. Isotope retention during radionuclide esophageal solid-emptying studies showed intermediate delay in emptying between normal subjects and achalasia patients. The duration of LES relaxation in this group was significantly shorter (p less than 0.01) than in normal subjects. Although complete, sphincter relaxation in these patients is functionally inadequate and may be the result of this shortened duration. The small size of standard manometry catheters may also contribute to this confusing finding. Apparent complete LES relaxation may be seen during manometry in achalasia and should not exclude its diagnosis.     

Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings

Compared with classic achalasia, vigorous achalasia has been defined as achalasia with relatively high esophageal contraction amplitudes, often with minimal esophageal dilation and prominent tertiary contractions on radiographs, and with the presence of chest pain. However, no study using current manometric techniques has compared manometric, radiographic, and clinical findings in vigorous and classic achalasia or questioned the usefulness of making this distinction. Fifty-four cases involving patients with achalasia whose radiographic and manometric studies were performed within 6 months of each other were available for review. Patients with vigorous achalasia (n = 17), defined by amplitude greater than or equal to 37 mm Hg, and patients with classic achalasia (n = 37), defined as amplitude less than 37 mm Hg, had substantial overlap in radiographic parameters of esophageal dilation, tortuosity, and tertiary contractions. Manometric properties of repetitive waves and lower esophageal sphincter pressure and clinical aspects of chest pain, dysphagia, heartburn, and satisfactory responses to pneumatic dilation were similar in both forms of achalasia. A separate analysis of patients with mean contraction amplitude greater than 60 mm Hg revealed similar findings. It is concluded that use of amplitude as a criterion for classifying achalasia is arbitrary and of dubious value.     

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。     

Optimal evaluation of patients with nonobstructive esophageal dysphagia

The aims of this study were to compare diagnostic accuracy, cost, and patient tolerance of videoesophagography and esophageal transit scintigraphy to esophageal manometry in the evaluation of nonobstructive esophageal dysphagia. Eighty-nine consecutive patients underwent videoesophagography, scintigraphy, and manometry. The sensitivities for diagnosing specific esophageal motility disorders, using esophageal manometry as the standard, were 75% and 68% for videoesophagography and scintigraphy, respectively, with positive predictive accuracies of 96% and 95% for achalasia, 100% and 67% for diffuse esophageal spasm, 100% and 75% for scleroderma, 50% and 67% for isolated LES dysfunction, 57% and 48% for nonspecific esophageal motility disorders, and 70% and 68% for normal esophageal motility. The cost for videoesophagography is less than that for either manometry or scintigraphy. Both videoesophagography and scintigraphy were better tolerated than manometry. It is concluded that videoesophagography and scintigraphy accurately diagnose primary esophageal motility disorders, achalasia, scleroderma, and diffuse esophageal spasm, but are less accurate in distinguishing nonspecific esophageal motility disorders from normal. When considering accuracy, cost, and patient acceptance, these findings suggest that videoesophagography is a useful initial diagnostic study for the evaluation of nonobstructive esophageal dysphagia.     

Multichannel intraluminal impedance monitoring in the evaluation of patients with non-obstructive Dysphagia

BACKGROUND: Non-obstructive dysphagia (NOD) often poses diagnostic problems. The aim of this study was to evaluate the value of the addition of multichannel intraluminal impedance (MII) recording to esophageal manometry in the work-up of patients with NOD. METHODS: A total of 40 consecutive patients with NOD underwent combined esophageal MII recording and perfusion manometry. Ten liquid and 10 viscous boluses were tested in each patient. Values for bolus presence time (BPT) at each of the four recording sites and total bolus transit time (TBTT) were calculated. Bolus transit (BT) was considered to be normal when BPT at all sites and TBTT were within the normal limits defined in 42 healthy subjects. Patients were judged to have normal transit if >or=80% of liquid and >or=70% of viscous swallows showed normal transit. RESULTS: The following manometric diagnoses were made: normal motility (20), ineffective esophageal motility (IEM) (13), diffuse esophageal spasm (DES) (4), and achalasia (3). Abnormal transit for liquid and/or viscous boluses was found in 35.3% of patients with normal motility, in 66.7% of DES patients, and in 100% of achalasia patients. In patients with achalasia quantification of BT was often made impossible by low initial impedance baseline. Two IEM patients (15.4%) showed normal liquid and viscous transit. Swallows showing normal transit had significantly longer duration of LES relaxation in patients with normal manometry and IEM (p < 0.05). CONCLUSIONS: MII recording identifies esophageal function abnormalities in NOD patients with normal manometry, IEM, and DES. The MII technique seems to be less suitable for the most severe end of the dysphagia spectrum like achalasia.     

经口内镜下肌切开术治疗贲门失弛缓症前后食管动力的变化

贲门失弛缓症的治疗目的为降低下食管括约肌压力(LESP),减轻梗阻,改善临床症状。经口内镜下肌切开术(POEM)近年来开始用于贲门失弛缓症的治疗。目的:通过分析手术前后食管动力的变化,评估POEM治疗贲门失弛缓症的近期疗效。方法:纳入2011年12月~2012年10月在南京鼓楼医院诊断为贲门失弛缓症并接受POEM治疗的39例患者,对其手术前后食管液态测压和近期随访结果进行回顾性分析。结果:38例患者完成POEM和术后3 d食管测压。术后3 d LESP较术前显著降低(P0.01),LES松弛率与术前相比无明显差异。术前和术后3 d食管体部均表现为蠕动性收缩消失,同步收缩比例增加。术后1个月随访,LESP仍显著低于术前(P0.05),37例患者吞咽困难明显好转,有效率为94.9%。结论:POEM治疗贲门失弛缓症近期内降低LESP和缓解临床症状效果明显,但对恢复食管蠕动功能作用有限。食管测压对贲门失弛缓症术后疗效评估有一定价值。     

Esophageal manometry: a comparison of findings in younger and older patients

Objective: We sought to determine the utility of esophageal manometry in an older patient population.
Methods: Consecutively performed manometry studies (470) were reviewed and two groups were chosen for the study, those ≥ 75 yr of age (66 patients) and those ≤ 50 years (122 patients). Symptoms, manometric findings (lower esophageal sphincter [LES], esophageal body, upper esophageal sphincter [UES]) and diagnoses were compared between the groups.
Results: Dysphagia was more common (60.6% vs 25.4%), and chest pain was less common (17.9 vs 26.2%) in older patients. In the entire group, there were no differences in LES parameters. Older patients with achalasia had lower LES residual pressures after deglutition (2.7 vs 12.0 mm Hg), but had similar resting pressures (31.4 vs 35.2 mm Hg) compared with younger achalasia patients. Duration and amplitude of peristalsis were similar in both groups, whereas peristaltic sequences were more likely to be simultaneous in the older group (15% vs 4%). The UES had a lower resting pressure in the older patients (49.6 vs 77.6 mm Hg) and a higher residual pressure (2.0 vs −2.7 mm Hg). The older patients were less likely to have normal motility (30.3% vs 44.3%) and were more likely to have achalasia (15.2% vs 4.1%) or diffuse esophageal spasm (16.6% vs 5.0%). When only patients with dysphagia were analyzed, achalasia was still more likely in the older group (20.0% vs 12.9%).
Conclusions: When older patients present with dysphagia, esophageal manometry frequently yields a diagnosis to help explain their symptoms.     

Esophageal manometry

Esophageal manometric study has gained tremendous popularity over the past decade. However, the contribution of this diagnostic technology has not been critically evaluated. The purpose of this report is, therefore, to determine how frequently esophageal manometry alters the clinical diagnosis and treatment and to assess the cost of new information. The patients reviewed in this report consisted of 363 consecutive referrals. Each completed a questionnaire, had an esophagogram, and underwent an esophageal manometric study for the evaluation of dysphagia, heartburn, and/or chest pain of unexplained etiology. To determine the clinical contribution of manometry, diagnoses before and after the study were compared. On the basis of symptoms and radiologic data, specific clinical entities were diagnosed in 36 patients. Manometric study did not confirm the diagnosis of achalasia in four of the 27 patients referred with this diagnosis and resulted in 19 additional specific diagnoses. Manometry changed the course of treatment in 14 cases, eight additional patients with achalasia received treatment, and four false-positive patients were spared inappropriate treatment. Moreover, two patients with simultaneous esophageal motor disorder and chest pain were spared further investigation. It is concluded that esophageal manometry altered the clinical diagnosis in 6% and changed the course of treatment in 4% of the population studied. Esophageal manometry is beneficial in patients with chest pain, dysphagia, and those in whom diagnosis of achalasia is suspected, but is of little benefit in patients with chronic heartburn. Assuming the cost per study to be $250, the cost of the study was $3945 per alteration of diagnosis and $6482 per alteration of treatment.     

Achalasia evolving from segmental aperistalsis

A 17-year-old woman was evaluated for dysphagia. Radiologic study revealed a rigid segment 10 cm long in the midesophagus, which was found to be aperistaltic on manometric evaluation. The rest of the esophagus and the lower esophageal sphincter were manometrically normal. Four years later the patient was seen for evaluation of severe dysphagia and symptoms of esophageal overflow. Characteristic radiologic and manometric findings of classic achalasia were noted. The case is discussed as an atypical form of achalasia evolving from a segmental esophageal aperistalsis.     

Correlation between the radiological observation of isolated tertiary waves on an esophagram and findings on high‐resolution esophageal manometry

Barium esophagrams are a frequently performed test, and radiological observations about potential abnormal esophageal motility, such as tertiary contractions, are commonly reported. We sought to assess the correlation between tertiary waves, and in particular isolated tertiary waves, on esophagrams and findings on non‐synchronous high‐resolution esophageal manometry. We retrospectively reviewed reports of esophagrams performed at a tertiary referral center and identified patients in whom tertiary waves were observed and a high‐resolution esophageal manometry had been performed. We defined two groups; group 1 was defined as patients with isolated tertiary waves, whereas group 2 had tertiary waves and evidence of achalasia or an obstructing structural abnormality on the esophagram. We collected data on demographics, dysphagia score, associated findings on esophagram, and need for intervention. We reviewed the reports of 2100 esophagrams of which tertiary waves were noted as an isolated abnormality in 92, and in association with achalasia or a structural obstruction in 61. High‐resolution manometry was performed in 17 patients in group 1, and five had evidence of a significant esophageal motility disorder and 4 required any intervention. Twenty‐one patients in group 2 underwent manometry, and 18 had a significant esophageal motility disorder. An isolated finding of tertiary waves on an esophagram is rarely associated with a significant esophageal motility disorder that requires intervention. All patients with isolated tertiary waves who required intervention had a dysphagia to liquids. Tertiary contractions, in the absence of dysphagia to liquids, indicate no significant esophageal motility disorder.     

Role of stationary esophageal manometry in clinical practice. Manometric results in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain.

The present study was carried out to evaluate the diagnostic usefulness of stationary esophageal manometry in 263 patients divided into three groups: 150 patients with reflux symptoms, 68 with dysphagia, and 45 with non-cardiac chest pain. Patients with endoscopic abnormalities were excluded. Standard manometry was performed following the station pull-through technique. In the group of patients with reflux symptoms 40.7% had a normal manometry and 57.3% had abnormalities, being the most frequent (43%) hypotensive lower esophageal sphincter. In the dysphagia group, 20.6% of manometries were normal and 79.4% were abnormal, of which achalasia was the most frequent disorder (53.7%). In the case of non-cardiac chest pain, 42.2% of patients had a normal manometry and 57.8% an abnormal one, of which hypotensive lower esophageal sphincter was the most frequent abnormality. A significant higher proportion of manometric alterations were found in the dysphagia group compared to reflux symptoms and non-cardiac chest pain (p < 0.05). No statistical differences were found between the reflux and the non-cardiac chest pain groups. Manometry yields a higher diagnostic value in patients with dysphagia, and therefore manometry should be performed routinely after the exclusion of any organic esophageal disease. Manometry is not a first-choice functional diagnostic test in the study of patirnts with gastroesophageal reflux or non-cardiac chest pain.