Chest pain in achalasia: patient characteristics and clinical course.

BACKGROUND & AIMS: In this prospective study, the prevalence of episodic pain in patients with achalasia was investigated, risk factors for its occurrence were determined, and its long-term clinical course was evaluated. METHODS: Over an 18-year period, patients with newly diagnosed achalasia were followed up at 2-year intervals. At the first visit and after each treatment, all patients underwent manometric, endoscopic, and radiographic examinations. In addition, structured interviews were performed during each patient visit and at 2-year intervals. Potential risk factors for the presence or absence of chest pain were evaluated with the use of a logistic model. To determine the evolution of this symptom, Kaplan-Meier life-table analyses were performed. RESULTS: Among 101 patients with achalasia, 64 reported chest pain and 37 had never had this symptom. Neither manometric nor radiographic findings predicted the occurrence of retrosternal pain. However, patients with chest pain were significantly younger than those without, and they had a shorter duration of symptoms. Treatment with pneumatic dilatation or myotomy effectively diminished dysphagia but had little effect on the occurrence of retrosternal pain. However, over a course of several years, chest pain diminished in most patients and disappeared in a minority of them. CONCLUSIONS: Chest pain is a common symptom of achalasia and predominantly affects younger patients. Its cause remains unknown, and no treatment exists to effectively relieve this symptom. However, with advancing age, the frequency of chest pain will spontaneously diminish in most patients.     

Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.     

Analysis of respiratory impedance characteristics in chronic bronchitis.

Impedance measurements of the respiratory system were performed by means of the technique of forced oscillations to study the mechanical characteristics of the respiratory system in 33 patients with chronic bronchitis without spirometric evidence of airway obstruction (FEV1 greater than or equal to 70% predicted). In 23 patients (69.7%) impedance was found to be abnormal. Inhalation of a beta 2-adrenergic drug (terbutaline) resulted in acute reversibility of these findings. In the 10 patients (30.3%) with a normal baseline respiratory impedance, isocapnic hyperventilation with cold air resulted in impedance characteristics similar to the abnormalities spontaneously occurring in the other group. These changes were found to be completely reversible after the inhalation of terbutaline. On the basis of these findings we conclude that impedance measurements of the respiratory system by means of the technique of forced oscillations allow the determination of mechanical airway abnormalities in patients with chronic bronchitis.     

Impedance characteristics of esophageal motor function in achalasia

Detailed data on patterns of esophageal bolus transport in patients with achalasia are still lacking. To study these we applied the novel technique of multichannel intraluminal impedance measurements. Ten patients with achalasia were studied using a 16 channel system. Liquid and semisolid boluses of 10 mL were applied with the patients in a supine position. Patterns of bolus transport were determined and analyzed as compared to results obtained from 20 healthy subjects. The healthy subjects featured a unique typical primary peristalsis pattern independent of bolus viscosity. In contrast, achalasia patients demonstrated different impedance characteristics, including: (i) significantly lower baseline esophageal impedance during the resting state as compared with healthy volunteers (999 omega +/- 108 versus 2749 omega +/- 113); (ii) failed bolus transport through the esophagus in all cases; (iii) impedance evidence of luminal content regurgitation in 35% of the swallows (iv) impedance evidence of pathological air movement within the proximal esophagus during deglutition in 38% of the swallows, so called air trapping. Thus, impedance characteristics of achalasia have been defined and can be attributed to known symptoms of achalasia. They can be used as basic findings for further classification of pathological bolus transports in other esophageal motility disorders.     

The myths and realities of hemochromatosis.

Hemochromatosis is a common genetic condition and yet there are still a number of misperceptions surrounding the diagnosis and management of this condition. Hemochromatosis affects both men and women. Typical patients do not have alcoholism or viral hepatitis, and often have normal liver enzymes. Clinical expression is highly variable. Genetic testing is widely available and particularly useful in family studies. Hemochromatosis can be readily diagnosed and treated. The purpose of the present review is to address the medical myths and misconceptions of hemochromatosis.     

Facts and myths on recurrent vulvovaginal candidosis--a review on epidemiology,clinical manifestations,diagnosis, pathogenesis and therapy

Approximately three-quarters of all women will experience an episode of vulvovaginal candidosis at least once in their life and 5-10% of them will have more than one attack. Women suffering from three to four attacks within 12 months will be diagnosed with recurrent vulvovaginal candidosis (RVVC). This review covers the large number of proposed aetiological factors for RVVC. The diagnosis of the condition made by conventional means by health providers is often false and is also often misdiagnosed by the affected woman herself. The review covers various methods of diagnosing RVVC and the current knowledge on potential pathogenetic mechanisms proposed for genital candida infections. Treatment of RVVC, including local and systemic antimicrobial therapy and behaviour modification to decrease the risk of recurrences, are discussed. Recent knowledge on drug resistance in candida is also included.     

贲门失驰缓症及滑动型食管裂孔疝患者食管多通道阻抗-压力测定分析

目的应用食管联合多通道阻抗-压力测定(MII-EM)技术研究贲门失驰缓症及滑动型食管裂孔疝患者的食管动力异常特点。 方法连续选取2013年4月至2014年6月到首都医科大学附属北京同仁医院就诊,入组内镜或食管造影诊断的贲门失驰缓症患者6名、滑动型食管裂孔疝患者10名以及健康志愿者10名行MII-EM检查,分析比较二个患病组与对照组间各检测指标差异。 结果与对照组相比,二个患病组的食团传送率均显著降低。贲门失驰缓症患者LES残余压显著升高,同步收缩及逆行收缩率明显增加,LES松弛率显著降低,食管中上段收缩压力也减低(P<0.05),但未发现其在LES静息压、LES长度、及UES各功能指标上的差异。滑动型食管裂孔疝患者LES静息压较对照组显著降低,UES舒张时间延长,食管近端收缩压力减低(P<0.05),但未发现食管中、下段收缩功能的异常。 结论MII-EM技术能够评估贲门失驰缓症及滑动型食管裂孔疝的食管功能障碍,具有一定的辅助诊断价值。     

Non-surgical treatment of achalasia.

The present-day treatment of achalasia is palliative and is aimed at reducing the lower esophageal sphincter pressure. Drug therapy with nitrates and nifedipine is beneficial for short-term relief in patients with relatively mild symptoms or as a temporary measure before a more definitive form of therapy. Balloon dilatation is the traditional non-surgical treatment of achalasia. Balloon dilatation is a safe procedure that can be used even when the esophagus is widened and tortuous, or when the patient is cachectic. The method of balloon dilatation used by the authors is described in detail. The immediate and late clinical, manometric and radiographic results of such dilatation are excellent and compare favorably with those of surgery. With balloon dilatation improvement is immediate, complications are rare and the risks are low. Morbidity and costs and the occurrence of stenosing reflux are considerably less than after surgical cardiomyotomy. Balloon dilatation is considered the treatment of choice for most patients with achalasia.     

Non-surgical management of achalasia.

Pneumatic dilatation of the cardia is an effective procedure to treat patients suffering from achalasia. Eighty percent of these patients can be expected to have excellent or good results for 6 years after the first dilatation. A repeat dilatation should be performed as soon as the patient has recurrent symptoms, usually every 2 years. Calcium channel blockers (nifedipine and verapamil) or nitrates (isosorbide dinitrate) decrease LES pressure but do little to the clinical symptomatology of patients with achalasia; however such drug therapy may be tried as an adjunct in patients who remain symptomatic after pneumatic dilatations or myotomy. Pneumatic dilatation and surgical myotomy both reduce LES pressure; with pneumatic dilatation, enough residual LES pressure is retained to prevent gastroesophageal reflux. Indeed, reflux esophagitis seems to occur more often after surgery than after forceful dilatations. We think that pneumatic dilatation should be performed as the primary therapy and surgery reserved for the failures of this procedure.     

Vasculitis. A collection of pearls and myths.

Important strides have been made in unraveling the pathophysiologic characteristics of some individual forms of vasculitis, but vasculitides continue to pose enormous challenges for clinicians. Over time, numerous myths and an occasional pearl have arisen from the care of patients with these disorders. In this collection of pearls and myths, we have attempted to pool our knowledge about the clinical care of vasculitis patients.     

Pneumatic dilation in achalasia.

Pneumatic dilation is the most common first-line therapy for the treatment of achalasia. The aim of dilation is a controlled disruption of circular muscle fibres of the lower esophageal sphincter to reduce the functional obstruction. Several types of dilators and different dilation techniques are used, but the achieved results are similar. The mean success rate is about 80% in the short term, but some patients need redilation in the further course (particularly young patients). Best long term results are obtained if the lower esophageal sphincter pressure can be reduced below 10 mmHg. Major complications are rare after pneumatic dilation; the most serious complication is esophageal perforation, which occurs at a mean rate of about 2.5%. Considering the pros and cons of other effective forms of treatment of achalasia (esophagomyotomy and intrasphincteric injection of botulinum toxin), pneumatic dilation is still the treatment of choice in the majority of patients with achalasia.