Identification of Achalasia Within Absent Contractility Phenotypes on High-Resolution Manometry: Prevalence, Predictive Factors, and Treatment Outcome.

INTRODUCTION: Absent contractility on high-resolution manometry (HRM) defines severe hypomotility but needs distinction from achalasia. We retrospectively identified achalasia within absent contractility using HRM provocative maneuvers, barium esophagography, and functional lumen imaging probe (FLIP). METHODS: Adult patients with absent contractility on HRM during the 4-year study period were eligible for inclusion. Inadequate studies, achalasia after therapy, or prior foregut surgery were exclusions. Upright integrated relaxation pressure (IRP) >12 mm Hg, panesophageal pressurization, and/or elevated IRP on multiple rapid swallows and rapid drink challenge (RDC) were considered abnormal. Esophageal barium retention and abnormal esophagogastric junction distensibility index (<2.0 mm 2 /mm Hg) on FLIP defined achalasia. Clinical, endoscopic, and motor characteristics of patients with achalasia were compared with absent contractility without obstruction. RESULTS: Of 164 patients, 20 (12.2%) had achalasia (17.9% of 112 patients with adjunctive testing), while 92 did not, and 52 did not undergo adjunctive tests. Achalasia was diagnosed regardless of IRP value, but the median supine IRP was higher (odds ratio 1.196, 95% confidence interval 1.041-1.375, P = 0.012). Patients with achalasia were more likely to present with dysphagia (80.0% vs 35.9%, P < 0.001), with obstructive features on HRM maneuvers (83.3% vs 48.9%, P = 0.039), but lower likelihood of GERD evidence (20.0% vs 47.3%, P = 0.027) or large hiatus hernia (15.0% vs 43.8%, P = 0.002). On multivariable analysis, dysphagia presentation ( P = 0.006) and pressurization on RDC ( P = 0.027) predicted achalasia, while reflux and presurgical evaluations and lack of RDC obstruction predicted absent contractility without obstruction. DISCUSSION: Despite HRM diagnosis of absent contractility, achalasia is identified in more than 1 in 10 patients regardless of IRP value.

Gastric residual volume after split-dose compared with evening-before polyethylene glycol bowel preparation.

BACKGROUND AND AIMS: Split-dose bowel preparation for colonoscopy results in superior preparation quality. However, some endoscopy units remain hesitant to prescribe split-dose preparation given theoretical concerns about possible aspiration caused by gastric residual fluid when a second dose is given close to the time of endoscopy. Our aim was to compare gastric residual volume (GRV) in patients taking split-dose bowel preparation and those taking preparation the evening before colonoscopy. METHODS: We performed a prospective observational comparison of GRV among random inpatients undergoing same-day EGD and colonoscopy either after a split-dose bowel preparation or after a bowel preparation the prior evening. RESULTS: GRV was measured in 150 patients undergoing EGD and colonoscopy: 75 who completed a split-dose bowel preparation 2 to 3 hours before endoscopy and 75 who completed the bowel preparation regimen the prior evening. The mean GRV 2 to 3 hours after the last ingestion of bowel preparation among split-dose group patients was 21 ± 24 mL (± standard deviation; range, 0 to 125 mL), which was not different from the mean GRV of 24 ± 22 mL (range, 0 to 135 mL) in patients who ingested the preparation the prior evening (P = .08). GRV had no association with the presence of diabetes, gastroparesis, or opioid use. CONCLUSIONS: GRV is the same after a split preparation and fasting for 2 to 3 hours or after preparation with overnight fasting. The data suggest that the risk of aspiration is identical after either preparation technique and thus that sedation for colonoscopy can be performed safely 2 hours after bowel preparation ingestion.

Profound hypoglycemia in starved, ghrelin-deficient mice is caused by decreased gluconeogenesis and reversed by lactate or fatty acids.

When mice are subjected to 7-day calorie restriction (40% of normal food intake), body fat disappears, but blood glucose is maintained as long as the animals produce ghrelin, an octanoylated peptide that stimulates growth hormone secretion. Mice can be rendered ghrelin-deficient by knock-out of the gene encoding either ghrelin O-acyltransferase, which attaches the required octanoate, or ghrelin itself. Calorie-restricted, fat-depleted ghrelin O-acyltransferase or ghrelin knock-out mice fail to show the normal increase in growth hormone and become profoundly hypoglycemic when fasted for 18-23 h. Glucose production in Goat(-/-) mice was reduced by 60% when compared with similarly treated WT mice. Plasma lactate and pyruvate were also low. Injection of lactate, pyruvate, alanine, or a fatty acid restored blood glucose in Goat(-/-) mice. Thus, when body fat is reduced by calorie restriction, ghrelin stimulates growth hormone secretion, which allows maintenance of glucose production, even when food intake is eliminated. In humans with anorexia nervosa or kwashiorkor, ghrelin and growth hormone are known to be elevated, just as they are in fat-depleted mice. We suggest that these two hormones prolong survival in starved humans as they do in mice.

A rare cause of melena.

Melanoma presenting in the gastrointestinal tract is commonly due to metastasis from a primary cutaneous or ocular lesion. There have been a few case reports of primary GI melanoma which is commonly seen in the rectum and anus. We report a case of a 77-year-old man who presented with GI bleeding and was found to have a primary small bowel melanoma. This case highlights how to approach the workup of a melanoma lesion found in the GI tract.