The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Role of symptoms, trend of liver tests, and endotherapy in management of post-cholecystectomy biliary leak.

AIM: Biliary leaks are widely reported complications of cholecystectomy, but standard management remains undecided. The objective of our study was to report the role of symptoms, biochemical tests, and ERCP in patients with a leak. MATERIALS AND METHODS: Twenty-one patients (8 M, 26-77 years) with suspected post-cholecystectomy biliary leak were retrospectively studied. Symptoms and liver tests (LTs) after surgery were monitored. Trends of LTs were considered positive if increases at >48 h were seen. ERCP was performed in all patients. Findings at endoscopy and treatments were reported. Outcome results were obtained for all patients. RESULTS: Seventeen of 21 patients had persistent biliary leak at ERCP, because of direct injury (n = 10), accessory duct (n = 4), or cystic duct stump (n = 3). Eleven of 17 patients (six without symptoms), had distal obstruction because of surgical injury (n = 8), stone (n = 2), or cholangiocarcinoma (n = 1) and underwent stenting (n = 4), naso-biliary drainage, NBD (n = 3), or surgery (n = 4). Among the six patients without obstruction (four without symptoms), stenting was performed in two and NBD in four. The four patients without apparent leak underwent NBD. Impairment of LTs was present in ten out of eleven (91%) patients with obstruction versus six of ten (60%) without obstruction. No complications occurred after ERCP. During a median follow-up of 33 months (cholangiocarcinoma excluded) all but one remained asymptomatic. CONCLUSIONS: Symptoms and trend of LTs were not predictive of biliary obstruction in patients with a leak after cholecystectomy. Both endotherapy and surgery had favorable outcomes.

[Functional intestinal disorders: how to improve diagnosis and treatment in general practice]. / Disordini funzionali intestinali: ottimizzare la gestione diagnostica e terapeutica nella pratica del medico di medicina generale.

The general practitioner is most likely to benefit from this "Opinion Paper" about the functional intestinal disorders, both as an update and as a tool to improve his/her relationship with patients. Four functional intestinal disorders have been described: irritable bowel syndrome, functional bloating, functional constipation and functional diarrhea. All such disorders are defined by non-specific symptoms, referred to the middle and/or lower gastrointestinal tract without evidence of any organic basis. Symptoms should have arisen at least six months earlier, and they should have recurred at least three times monthly over the last three months. Disorders of motility, visceral hypersensitivity, inflammatory and immune disorders, as well as psycho-social, genetic and environmental factors, have all been involved in the pathophysiology of functional intestinal disorders; disturbances of the colonic bacterial flora are also suggested to have a leading role and interventions to correct them are most useful. Functional intestinal disorders as described in the validated Rome III Criteria are possibly too much categorized, but such criteria still are the only useful tool for diagnosis and therapeutic choices. Clinical history is crucial for diagnosis, meaning when symptoms were first detected and how they evolve, alternate, and associate. A diagnostic diary to report symptoms, daily activities, and foods may also be helpful. Functional intestinal disorders persist over time, and they heavily interfere with quality of life; they also have a heavy impact on economical resources. However, intestinal functional disorders are not associated with dangerous sequelae or mortality. It is up to general practitioners to reassure patients and to prescribe first-level diagnostic exams appropriately.

Analysis of patients attitude to undergo urgent endoscopic procedures during COVID-19 outbreak in Italy.

We conducted a survey to investigate to what extent the fear of COVID-19 has influenced the patients decision to undergo or to cancel endoscopic procedures. We collected data from 847 patients from 13 centres. The main indication for endoscopy was anemia, followed by pain and unexplained weight loss. The percentage of not presenters progressively increased throughout the three weeks of study, from 15.1% at the beginning to 48.2% at the end. 37 (34.2%) upper GI endoscopies and 112 (56.3 %) colonoscopies showed an organic cause explaining the symptoms presented by the patients, respectively; 5 cases of gastric cancer (4.6%) and 16 cases of colorectal cancer (CRC) (6.0%), respectively, were detected; during the second week the percentage of organic diseases found at upper endoscopy was 19 (33.3%) with 5 cancer (8.7%), and 61 (49.1% ) at colonoscopy, with 2 CRC (1.6%); finally, during the third week the corresponding figures were 19 (48.7%) for upper GI examinations, with 3 gastric cancers (7.7%), and 43 (60.5%) with 4 (6.5%) CRC cases found.We conclude that patients weighted the fear of having a clinically relevant disease with the fear of becoming infected by coronavirus, and a relevant percentage of them (29.4%) decided not to attend the endoscopy suites at the scheduled date.

Optimal number of multiple rapid swallows needed during high-resolution esophageal manometry for accurate prediction of contraction reserve.

BACKGROUND: Multiple rapid swallows (MRS) is a provocative test for assessment of contraction reserve, however reproducibility on repetitive MRS is incompletely understood. Our aim was to determine the optimal number of MRS sequences for consistent assessment of contraction reserve. METHODS: One hundred and fifty-nine consecutive patients (79 IEM and 80 normal motility) who underwent high-resolution manometers were enrolled. Ten single swallows (SS) and 10 MRS were performed. Gold standard for evaluation of the contraction reserve was the ratio between the mean DCI of 10 MRS and the mean DCI of 10 SS (MRS/SS DCI ratio). Rates of false negatives and false positives were calculated for increasing numbers of MRS sequences, using either mean DCI or the MRS with the highest DCI. KEY RESULTS: According to the gold standard, 50 IEM and 50 normal motility patients had contraction reserve. With progressively increasing numbers of MRS sequences, contraction reserve was detected using mean MRS DCI within three and four MRS sequences in IEM and normal motility respectively, whereas two and three MRS sequences were needed using the MRS sequence with the highest DCI. False positives were much higher with highest DCI method compared with mean DCI, (22% vs 9% respectively in IEM; 24% vs 9% in normal motility) when three MRS sequences were considered. CONCLUSIONS & INFERENCES: At least three MRS are needed to reliably assess contraction reserve. The mean DCI of the three MRS sequences is the best variable to utilize as evidence of contraction reserve.

Multiple rapid swallowing in idiopathic achalasia: evidence for patients' heterogeneity.

In order to evaluate the function of inhibitory neural pathways in achalasia, we compared the response of the oesophageal body and lower oesophageal sphincter (LOS) to single swallows (SS) and multiple rapid swallowing (MRS) in 20 consecutive patients with untreated idiopathic achalasia (10 men, aged 23-81 years) and in 20 control patients without dysphagia (nine men, aged 31-73 years), using sleeve manometry; 277 SS and 85 MRS were analysed. In the control group, MRS inhibited motor activity in the oesophageal body and induced a slightly lower (P < 0.05) nadir LOS pressure compared with SS. In the achalasia patients, MRS induced a variable response: eight patients had simultaneous motor activity during all MRS although onset was delayed compared with SS [median (interquartile range), 3.5 s (1.7-6.1) vs 1.4 s (0.8-3.9); P < 0.05], whereas eight patients showed motor inhibition which occurred during all MRS in four of them, and the remaining four had no motor activity both after SS and during MRS. Overall MRS did not decrease nadir LOS pressure compared with SS [12 mmHg (5-20) vs 16 mmHg (7-22); P > 0.1]; however, it induced complete LOS relaxation in three of the patients. MRS gives further evidence of functional heterogeneity among achalasia patients.

Wireless pH monitoring: better tolerability and lower impact on daily habits.

BACKGROUND: Twenty-four hours oesophageal pH monitoring is considered the reference-standard for the diagnosis of gastro-oesophageal reflux disease, but it is limited by catheter discomfort and limitations of daily habits. AIM: We evaluated tolerability and impact on food intake and daily activities of catheter-based compared to wireless pH monitoring. PATIENTS: One-hundred and thirty-three consecutive patients with suspected gastro-oesophageal reflux disease were enrolled. METHODS: Seventy-eight patients (36 M, 53+/-2 years) underwent the 24 h catheter-based and 55 patients (25 M, 44+/-3 years) the 48 h wireless pH monitoring. Discomfort at placement and during the test was evaluated by 100 mm visual analogue scales. Limitations of food intake and of daily activities were evaluated by standardized questionnaires (score 0 to 3). RESULTS: Discomfort (mean+/-standard error of the mean) at placement and during the test was 32+/-3 versus 29+/-4 (p=ns) and 37+/-3 versus 22+/-3 (p<0.001) for the catheter-based versus wireless techniques. Limitation of food intake and of daily activities (mean+/-standard error of the mean) were 0.9+/-0.1 versus 0.4+/-0.1 (p<0.05) and 1.2+/-0.1 versus 0.2+/-0.1 (p<0.0001), respectively. CONCLUSIONS: The wireless pH monitoring is better tolerated and has minor impact on daily habits compared to the traditional technique. Whether this translates into better diagnostic accuracy remains to be evaluated.

Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry.

BACKGROUND: Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. METHODS: Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non-events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria. KEY RESULTS: All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non-events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria. CONCLUSION & INFERENCES: Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition.

Gastro-esophageal reflux and antisecretory drugs use among patients with chronic autoimmune atrophic gastritis: a study with pH-impedance monitoring.

BACKGROUND: Patients with chronic autoimmune atrophic gastritis (CAAG) often refer digestive symptoms and are prescribed antisecretory medications. Aims were to investigate: (i) gastro-esophageal reflux (GER), (ii) psychopathological profile, (iii) frequency of use and clinical benefit of antisecretory drugs. METHODS: Prospective observational study on 41 CAAG patients who underwent: 24 h multichannel intra-luminal impedance-pH (MII-pH) monitoring off-therapy, standardized medical interview and psychological questionnaire (i.e., SCL-90R). The medical interview was repeated at least 1 month after MII-pH in patients who were using antisecretory drugs. Statistical analysis was performed calculating median (10th-90th percentiles) and risk ratios (RR) with 95% confidence interval. KEY RESULTS: Median intra-gastric pH was 6.2 (4.6-7.0). One patient had acid reflux (AC) associated with symptoms, five had increased total reflux number and four had symptoms associated to non-acid reflux (NA) (patients referred as 'GER positive'). Using patients 'GER negative' with normal SCL-90R as reference, the RR of being symptomatic in patients GER positive was 2.1 (1.1-4.1) if SCL-90R was normal and 0.9 (0.5-1.7) if it was altered (difference in RR significant being p = 0.04). Seventeen/28 (61%) symptomatic patients were on antisecretory drugs, which were stopped in 16 of them according to results of MII-pH and clinical evaluation after 574 days (48-796) showed that symptoms were unchanged. CONCLUSIONS & INFERENCES: In patients with CAAG (i) AC reflux rarely occurred whereas increased NA reflux was not infrequent both being related to symptoms in some patients, (ii) psychopathological profile has a role in symptoms' occurrence, (iii) antisecretory drugs were generally inappropriately used and clinically ineffective.

Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases.

Ringed oesophagus is an increasingly recognised finding in young people presenting with dysphagia and may be related to eosinophilic oesophagitis. Recently, hypotheses regarding potential aetiologies have been proposed but these have not been systemically tested in the majority of reported cases. We report two cases very similar in clinical history and endoscopic findings. An association with gastro-oesophageal reflux disease or motility abnormalities of the oesophagus were ruled out in both. Histological analysis revealed high-density infiltration of the oesophageal mucosa by eosinophils and excluded gastro-duodenal involvement. Examinations of the oesophagus at the time of low frequency dysphagia, some years before presentation to our centre, did not show rings, suggesting that multiple rings are a possible late complication of eosinophilic oesophagitis. Oesophageal dilatation effectively relieved dysphagia in our two patients.

Impact of referral for gastro-oesophageal reflux disease on the workload of an academic Gastroenterology Unit.

BACKGROUND: Gastro-oesophageal reflux disease is known to be a frequent cause of patients' referral to hospital gastroenterologists. AIM: To increase knowledge on referral for reflux disease, in an Italian academic setting. PATIENTS AND METHODS: The impact of gastro-oesophageal reflux disease on 1 year's workload, comprising upper endoscopy, outpatients' consultations in the general clinic, oesophageal pH monitoring and oesophageal manometry was retrospectively assessed. Appropriateness of oesophageal pH monitoring and oesophageal manometry was also evaluated. RESULTS: Endoscopy: Out of 2269 upper endoscopies reflux symptoms comprised 16.9% (n=386) of referrals; 19.1% only of these 386 patients had erosive oesophagitis at endoscopy and none had oesophagogastric malignancies (68% of the patients were >45 years). Consultations: Thirty-three percent out of 553 patients were referred for reflux symptoms. Upper endoscopy had already been performed before consultation in 64% of them. pH monitoring and oesophageal manometry: Two hundred and sixteen oesophageal pH monitorings and 160 oesophageal manometries were performed and 29% and 28%, respectively, were inappropriate, being performed in the diagnostic work-up of patients with typical reflux symptoms. CONCLUSIONS: At an academic Gastroenterology Unit, (a) gastro-oesophageal reflux disease is a frequent referral for upper endoscopy and consultations, (b) prevalence of oesophagitis is low, (c) consultation is preceded by endoscopy in the majority of patients and (d) oesophageal pH monitoring and oesophageal manometry are often inappropriately used.

Gastric involvement in a patient with secondary syphilis.

A 30-year-old man was referred because of a short lasting history of severe epigastric pain and early satiety, with remarkable weight loss. Physical examination was fully consistent with secondary syphilis and upper GI tract endoscopy revealed multiple gastric mucopurulent erosions and several nodular lesions ranging from 2 to 3 cm in diameter, with central crater, abruptly ending at the pyloric level. Appropriate antibiotic treatment obtained a dramatic improvement and complete reversal of cutaneous and gastric lesions.

Review article: gastro-oesophageal reflux disease--pathophysiological issues of clinical relevance.

Gastro-oesophageal reflux disease is a multifactorial disorder in which the pathophysiological mechanisms are variably combined in different patients. Motor dysfunction of the lower oesophageal sphincter (LOS) and, possibly, the proximal stomach is a major cause of the increase in the number of reflux episodes. Transient LOS relaxation is the main mechanism of reflux in many patients with endoscopically negative disease, whereas a hypotensive LOS becomes relevant only in patients with oesophagitis. Alterations in primary and secondary peristalsis contribute to the increased oesophageal acid exposure by delaying clearance. The presence of a hiatus hernia, especially when voluminous and/or non-reducible, increases the number of reflux episodes by mechanically weakening the oesophago-gastric junction, and impairs oesophageal clearance. Hypersensitivity to acid is often present and contributes to the clinical manifestations of the disease, whereas oesophageal hypersensitivity, both to chemical and mechanical stimuli, plays a predominant role in a subset of patients. Increased concentrations of noxious compounds in the oesophageal refluxate may contribute to the development of anatomical lesions, but this is still a matter for debate. The clinical relevance of Helicobacter pylori infection and of mucosal defensive factors still needs to be fully elucidated.

Effect of non-selective gamma-aminobutyric acid receptor stimulation on motor function of the lower oesophageal sphincter and gastro-oesophageal reflux in healthy human subjects.

BACKGROUND: Transient lower oesophageal sphincter relaxation and low lower oesophageal sphincter pressure are the main mechanisms of reflux. It has recently been shown that the stimulation of gamma-aminobutyric acid type B (GABAB) receptors by baclofen decreases the rate of transient lower oesophageal sphincter relaxation and increases the lower oesophageal sphincter pressure in healthy humans. Valproic acid increases synaptosomal GABA concentrations, thus affecting all types of GABA receptors. AIM: To evaluate the effect of valproic acid on transient lower oesophageal sphincter relaxation, lower oesophageal sphincter pressure and gastro-oesophageal reflux. METHODS: Thirteen healthy subjects underwent 2-h post-prandial oesophageal motility and pH monitoring on two separate occasions after the oral administration of 1 g valproic acid or placebo. RESULTS: Valproic acid increased the lower oesophageal sphincter pressure by 41% (14.0 +/- 2.1 mmHg vs. 9.9 +/- 2.0 mmHg after placebo, P<0.02), but did not affect the rate of transient lower oesophageal sphincter relaxation (7.9 +/- 1.0/h vs. 8.2 +/- 0.9/h after placebo), the number of reflux episodes or gastro-oesophageal reflux. CONCLUSIONS: Non-selective GABA receptor stimulation may be beneficial to reflux patients with low lower oesophageal sphincter pressure, but exerts a different modulation of transient lower oesophageal sphincter relaxation than the selective stimulation of GABAB receptors.

Quantification of the oesophageal peristaltic reflex in man.

The peristaltic reflex represents the basis of peristalsis and has two components, ascending contraction above and descending relaxation below the site of distension. Studies of the two components of the reflex in the human oesophagus performed by concurrent monitoring of oesophageal body and lower oesophageal sphincter (LOS) motility are lacking. We investigated the peristaltic reflex in eight healthy volunteers (aged 19-25 years; five male, three female) by two series of eight graded (3-10 mL) balloon distensions performed 11 cm above the LOS, monitoring motor activity in the oesophageal body both above and below the balloon and in the LOS (sleeve sensor). During balloon distension both ascending contraction, as assessed by contractile activity above the balloon, and descending relaxation, as assessed by LOS relaxation, increased linearly with increasing inflation volumes (r = 0.6 and r = 0.8, respectively, both P < 0.0001). The threshold for descending relaxation was lower than that for ascending contraction. The contractile response of the body below the balloon was always lower than above the balloon and occurred with a higher (P < 0.05) frequency at 6 and 7 mL compared to 3, 4 and 10 mL. After balloon deflation an oesophageal contraction, usually accompanied by an LOS contraction, occurred with increasing frequency as the balloon volume increased. Our experimental model allows detailed assessment of the two components of the peristaltic reflex in the human oesophagus in vivo and should prove useful in future studies on the physiology and pathophysiology of this reflex.

An experimental model for the study of transient lower oesophageal sphincter relaxation and motor function of the proximal stomach in humans.

A simple and reliable experimental model would be useful in human research on new drugs which target transient lower oesophageal sphincter (LOS) relaxation. The aim was to investigate the effect of repeated distensions on the rate of transient LOS relaxation, LOS pressure and motor function of the proximal stomach. Twelve healthy subjects were studied with a multilumen manometric assembly incorporating a sleeve sensor for the LOS and a bag positioned in the proximal stomach and connected to a barostat. Intrabag volume was set at 75% of the threshold for gastric discomfort and maintained for two 30-min distension periods separated by a 45-min washout with the bag deflated. The studies lasted 145 +/- 2 min. The rate of transient LOS relaxations was similar during the two distensions, 3.5;2-4 vs 3;2.5-4 (median;interquartile range) and so was LOS pressure. Baseline intrabag pressure, as a measure of gastric tone, and the number of pressure waves, as a measure of phasic contractions, were also similar, 11.3;9.3-12.3 mmHg vs 10.8;9.3-12.5 mmHg and 16;13-28 mmHg vs 19;15-29 mmHg, respectively. Our model allows to perform 1-day studies which can assess two experimental conditions on transient LOS relaxations and motor function of the proximal stomach within an acceptable time span.

Motor events underlying gastro-oesophageal reflux in ambulant patients with reflux oesophagitis.

Information on the mechanism of gastro-oesophageal reflux in patients with reflux disease is limited largely to studies in resting recumbent subjects. Evidence exists that both posture and physical activity may influence reflux. The aim of this study was to investigate reflux mechanisms in ambulant patients with reflux oesophagitis. Concurrent ambulatory oesophageal manometry and pH monitoring were performed in 11 ambulant patients with erosive oesophagitis. Lower oesophageal sphincter (LOS) pressure was monitored with a perfused sleeve sensor. Recordings were made for 90 min before and 180 min after a meal. At set times patients sat in a chair or walked. LOS pressure was < or = 2 mmHg at the time of reflux for 98% of reflux episodes. Transient LOS relaxation was the most common pattern overall and the predominant pattern in seven patients, whilst persistently absent basal LOS pressure was the most common pattern in four patients. The pattern of LOS pressure was not altered by the presence of hiatus hernia or by walking. Straining occurred at the onset of 31% of acid reflux episodes but often followed the development of an oesophageal common cavity. The occurrence of straining was not influenced by walking. In ambulant patients with reflux oesophagitis: (1) LOS pressure is almost always absent at the time of reflux, usually because of transient LOS relaxation, (2) persistently absent basal LOS pressure is an important mechanism of reflux in a few patients, (3) straining may help to induce acid reflux in a variable proportion of occasions and may in some instances be a response to gas reflux, and (4) walking does not influence the occurrence of reflux or its mechanisms.

Fat and gastro-oesophageal reflux disease.

It is common practice to prescribe avoidance of fatty foods to patients with gastro-oesophageal reflux disease; however, there is no good evidence supporting the benefit of such a prescription. Several reports looking at gastro-oesophageal reflux after meals of different fat content have been controversial probably because of differences in caloric load, volume and osmolarity, factors which may independently influence reflux. Recent observations suggest that fatty meals do not promote gastro-oesophageal reflux nor alter the competence of the oesophagogastric junction in comparison to balanced meals, provided they contain the same energy load. The possibility that fat increases heartburn by modulating perception of acid reflux seems to have little relevance. It is concluded that, in the light of present evidence, there is no sound rationale for clinicians recommending that patients with GORD follow a low-fat diet.

Bile reflux and oesophagitis.

Duodenal contents, and especially bile acids and trypsin, are noxious to the oesophageal mucosa, their damaging potential depending on pH. Various methodologies have been used to measure duodenogastric or duodenogastro-oesophageal reflux, all of them having technical limitations. Controversy exists as to the extent of duodenogastric reflux in GORD. Reflux of both acid and duodenal contents into the oesophagus increases with worsening of oesophagitis. Experimental data suggest that bile acids and trypsin are noxious to the oesophageal mucosa and that their damaging potential depends on pH. The injurious concentrations are, however, higher than those usually observed in the human oesophagus. Direct measurement of bile acids and trypsin is difficult and various methodologies have been used to measure duodenogastric or duodenogastro-oesophageal reflux, all of them having technical limitations. Whereas available data as to the extent of duodenogastric reflux in gastro-oesophageal reflux disease (GORD) are controversial, most observations show that reflux of both acid and duodenal contents into the oesophagus increases with worsening of oesophagitis. Furthermore, acid and duodenal contents occur simultaneously in most reflux episodes. In this issue of the journal, Marshall et al. report that exposure of the gastric fundus to duodenal contents as assessed by bilirubin monitoring is similar in GORD patients with varying degrees of oesophageal mucosal injury and in healthy controls.

Spontaneous perforation of an oesophageal diverticulum in achalasia.

Spontaneous perforation of the oesophagus is a rare occurrence that is usually due to vomiting and is seldom associated with an oesophageal lesion. We report a case of the spontaneous perforation of a large oesophageal diverticulum not preceded by any precipitating event in a 75-year-old male who was not known to have achalasia. The diverticulum was repaired by emergency surgery. Achalasia was later diagnosed and successfully treated with botulin toxin injection. Surgery decision-making and the treatment of achalasia are discussed.