Specific movement of esophagus during transient lower esophageal sphincter relaxation in gastroesophageal reflux disease.

BACKGROUND/AIMS: Transient lower esophageal sphincter relaxation (TLESR) is the main mechanism of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the characteristics of transient lower esophageal sphincter movement in patients with or without gastroesophageal reflux by high-resolution manometry (HRM). METHODS: From June 2010 to July 2010, we enrolled 9 patients with GERD (GERD group) and 9 subjects without GERD (control group), prospectively. The manometry test was performed in a semi-recumbent position for 120 minutes following ingestion of a standardized, mixed liquid and solid meal. HRM was used to identify the frequency and duration of TLESR, esophageal shortening length from incomplete TLESR, upper esophageal sphincter (UES) response, and the related esophageal motor responses during TLESR. RESULTS: TLESR occurred in 33 in the GERD group and 34 in the control group after 120 minutes following food ingestion. Duration of TLESR and length of esophageal shortening did not differ between 2 groups. UES pressure increase during TLESR was mostly detected in patients with GERD, and UES relaxation was observed frequently in the control group during TLESR. TLESR-related motor responses terminating in TLESR were predominantly observed in the control group. CONCLUSIONS: Increased UES pressure was noted frequently in the GERD group, suggesting a mechanism for preventing harmful reflux, which may be composed mainly of fluid on the larynx or pharynx. However, patients with GERD lacked the related motor responses terminating in TLESR to promote esophageal emptying of refluxate.

Symptomatic improvement of diffuse esophageal spasm after botulinum toxin injection.

Diffuse esophageal spasm, an uncommon esophageal motility disorder, has recently been defined using high-resolution manometry. Patients with distal esophageal spasm usually complain of chest pain or dysphagia. The etiology and pathophysiology of this disorder are poorly known, and treatment options are limited. However, some options to improve symptoms are available, including endoscopic injection of botulinum toxin. Nevertheless, few reports have described the effects of endoscopic injection of botulinum toxin in patients with symptomatic diffuse esophageal spasm with clear endoscopic and high-resolution manometry images. Here, we report a case of diffuse esophageal spasm diagnosed with high-resolution manometry and treated by endoscopic injection of botulinum toxin with good results at the 7-month follow-up.

Holmium laser lithotripsy under direct peroral cholangioscopy by using an ultra-slim upper endoscope for patients with retained bile duct stones (with video).

BACKGROUND: Direct peroral cholangioscopy (POC) by using an ultra-slim endoscope provides direct visualization of the bile duct and allows for therapeutic intervention. Holmium laser lithotripsy can be effective for retained bile duct stones, but it requires direct visualization during the procedure for safe and effective fragmentation. Direct POC by using an ultra-slim endoscope may facilitate holmium laser lithotripsy. OBJECTIVE: To evaluate the feasibility, success rates, and complications of holmium laser lithotripsy under direct POC by using an ultra-slim endoscope for retained bile duct stones. DESIGN: Observational clinical feasibility study. SETTING: Tertiary-care referral center. PATIENTS: This study involved 13 patients with retained bile duct stones whose treatment failed by a conventional lithotripsy method involving mechanical lithotripsy. INTERVENTION: Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope. MAIN OUTCOME MEASUREMENTS: Success rate of complete stone removal and procedure-related complications. RESULTS: Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was successful in 11 of 13 patients (84.6%). Although direct POC was successful, holmium laser lithotripsy failed in 2 patients because of inaccurate targeting of the laser fiber to stones. There were no procedure-related complications except one case of mild pancreatitis. LIMITATIONS: A small number of patients and no comparison with other lithotripsy systems. CONCLUSION: Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was feasible and can be a safe endoscopic management method for retained bile duct stones.