Jackhammer esophagus: Prevalence and demographic, clinical, and manometric characteristics. / «Jackhammer esophagus¼ (esófago en martillo hidráulico): prevalencia, características demográficas, clínicas y manométricas.

INTRODUCTION AND AIMS: Jackhammer esophagus is a recently identified motility disorder. Experience with the novel pathologic condition has been reported in different studies but there is little information on the subject in Latin America. Our case series conducted in Bogota, Colombia, describes the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics. MATERIALS AND METHODS: A retrospective, observational, cross-sectional study included consecutive patients diagnosed with jackhammer esophagus that were referred for high-resolution esophageal manometry. Their clinical and manometric records were reviewed, and the pertinent information for the present study was collected. RESULTS: Within the study period, 6,445 patients were evaluated with esophageal manometry, 27 of whom were diagnosed with jackhammer esophagus (prevalence of 0.42%). The majority of those patients were women (n=17, 63%) in the sixth decade of life. The most common symptom was regurgitation (n=17, 63%), followed by dysphagia (n=15, 56%). The mean distal contractile integral was 9,384 (5,095-18,546) mmHg·s·cm. Dysphagia was more common in patients >60 years of age (79%, p <.01) and regurgitation was more frequent in patients <60 years of age (92%, p <.03). CONCLUSIONS: The present study is the first to characterize the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics in Latin American patients. The prevalence of jackhammer esophagus in our study population was considerably lower than that reported in international case series. Our findings suggest that there are important geographic differences in the epidemiology and clinical presentation of jackhammer esophagus, compared with data from other international centers.

The Mexican consensus on non-cardiac chest pain. / Consenso mexicano sobre dolor torácico no cardiaco.

INTRODUCTION: Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM: To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS: Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS: The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

High-resolution esophageal manometry in a Mexican population: diagnostic outcome.

High-resolution esophageal manometry (HREM) has become the method of choice for evaluation of esophageal motility disorders. There is a paucity of data with this technique from Hispanic countries. This study aims to characterize the diagnostic outcome of HREM in a large cohort of consecutive patients in Mexico.This study was conducted in Monterrey, Mexico from March 1, 2013 to March 31, 2015. Our diverse study population included patients from a major academic institution and the community. HREM was done applying the Chicago Classification 3. Diagnostic outcome was grouped as weak peristaltic disorders, gastroesophageal junction disorders, and hypertensive/uncoordinated peristalsis.We studied 670 consecutive patients, 57% were women, mean age was 43.8 years. The majority (465 [69%]) were referred for preoperative evaluation of gastroesophageal reflux disease (GERD), 365 (78%) of whom had a normal study. Overall, 193 (29%) patients had abnormal motility, the most common disorder being weak peristalsis (104 [54%]). In patients with dysphagia, the most frequent finding was achalasia (23/46 [50%]).To our knowledge, this is the first study to characterize the diagnostic outcome of HREM in a large cohort of Hispanic patients in Latin America. At our open access center, 69% of patients were referred for preoperative evaluation of GERD, reflecting the popularity of antireflux surgery. This study confirms the high prevalence of weak peristalsis and highlights the importance of addressing its pathophysiology and management. The finding of achalasia in 50% of our patients with dysphagia is consistent with recent reports regarding the rising incidence of this disorder and underscores the need of prompt motility testing in this population.

Nutcracker esophagus: demographic, clinical features, and esophageal tests in 115 patients.

Nutcracker esophagus (NE) is a common esophageal motility disorder chacterized by high amplitude peristaltic contractions in the distal esophagus. While previous studies have examined selected aspects of this condition (e.g. pathogenesis and treatment), there is a paucity of data regarding demographic and clinical features in large cohorts of patients. The aim of this study was to describe demographics, clinical features, comorbidities, time to diagnosis, source of patient referral by specialty, and medication use in a large cohort of patients with NE. We retrospectively analyzed consecutive cases of NE diagnosed from 2008-2010. The electronic medical records of these patients were reviewed, and relevant information was extracted. We identified 115 patients with NE. The median age was 62 years (range 25-87 years), and 63% were female. The median time patients experienced symptoms prior to diagnosis was 24 months (0-480 months). Most patients presented to an internal medicine consultant (42%) or to a gastroenterologist (35%). Presenting symptoms were chest pain (31%) and dysphagia (21%). Gastroesophageal reflux disease (GERD) symptoms were common: heartburn occurred in 51% of patients, 77% had a prior history of GERD, and 78% were receiving acid suppressive medications. GERD was confirmed by testing in at least 35%. Psychiatric comorbidity occurred in 24% with half the patients receiving psychotropic medications. Irritable bowel syndrome (IBS) and fibromyalgia co-existed in 15% and 12% of patients, respectively. Surprisingly, opioids were prescribed to 26% of patients. No statistically significant correlation was found between esophageal motility parameters and symptoms. In this study, NE patients were more commonly middle-aged females experiencing a considerable amount of time between symptom onset and diagnosis. Many were initially evaluated by internists for dysphagia or chest pain and had a history of GERD. Medication prescribed prior to diagnoses frequently involved acid suppression, but narcotic and psychotropic prescriptions were also commonly used. Central sensitization syndromes (fibromyalgia and IBS), psychiatric comorbidity, and reflux commonly coexisted. Our study suggests that future investigations should address the role and interaction of GERD and psychiatric disorders in NE.

The outcome of patients with oesophageal eosinophilic infiltration after an eight-week trial of a proton pump inhibitor.

BACKGROUND: Current diagnostic guidelines recommend that eosinophilic oesophagitis (EoE) should be diagnosed only after GERD is excluded by a lack of response to a trial of acid suppression. There is limited information available providing outcome data about the effectiveness of this approach. AIM: To examine the impact of double-dose proton pump inhibitor (PPI) therapy on symptoms, endoscopic and histological features in patients with documented oesophageal eosinophilia consistent with EoE (≥15 eosinophils/high-power field). METHODS: Sixty consecutive symptomatic patients with documented oesophageal eosinophilia received open-label omeprazole 20 mg orally twice daily before meals for 8 weeks. Clinical, endoscopic and histological (resolution: 0-5 eosinophils/HPF, partial improvement: 5-14 eosinophils/HPF), or no improvement: (≥15 eosinophils/HPF) evaluation was repeated at the end of this period. An expert GI pathologist, unaware of the study aims, reviewed all slides. RESULTS: Clinical improvement occurred in 43 (71.6%), endoscopic signs were reduced in 34 (61.8%) and normalised in 12 (21.8%), and histologically, 34 (56.6%) improved, while 15 (25%) obtained complete resolution. Overall, 22 patients (36.7%) obtained both complete clinical and histological remission. CONCLUSIONS: More than 50% of patients with documented oesophageal eosinophilic infiltration in the EoE range improved when treated with a double-dose PPI trial for 8 weeks. These findings support the published guidelines recommending a PPI trial prior to diagnosing EoE, and confirm the existence of an eosinophilic oesophageal infiltrationPPI-responsive population.

Noncardiac chest pain: diagnostic evaluation.

Noncardiac chest pain (NCCP) is a common and challenging clinical problem. It is estimated that more than 70 million Americans (23% of the population) suffer from this condition yearly. Patients with NCCP represent a diagnostic dilemma. Their chest pain is often indistinguishable from cardiac pain leading to extensive and expensive evaluations. Once coronary artery disease and other cardiac and pulmonary sources of chest pain are excluded, patients are frequently referred to gastroenterologists to look primarily for esophageal sources of pain. A variety of diagnostic tests are available to the practicing clinician to identify the origin of pain, including ambulatory pH testing, esophageal motility, upper endoscopy, provocative testing and even therapeutic trials.

Esophageal spasm: demographic, clinical, radiographic, and manometric features in 108 patients.

Diffuse esophageal spasm (DES) remains insufficiently understood. Here we aimed to summarize the demographic, clinical, radiographic, and manometric features in a large cohort of patients with DES. We identified all consecutive patients diagnosed with DES from 2000 to 2006 at Mayo Clinic Florida. The computerized records of these patients were reviewed to extract relevant information. We performed 2654 esophageal motilities during that period. There were 108 patients with esophageal spasm, and 55% were female. Median age was 71 years. The most common leading symptom was dysphagia in 55, followed by chest pain in 31. Weight loss occurred in 28 patients. The median of time from onset of symptoms to diagnosis was 48 months (range 0-480), with a median of time from the first medical consultation to diagnosis of 8 months (range 0-300). The most frequent comorbidities were hypertension and psychiatric problems. At presentation, 81 patients were taking acid-reducing medications, and 49 patients were taking psychotropic drugs. An abnormal esophagogram was noted in 46 of 76 patients with this test available, but most radiographic findings were nonspecific with the typical 'corkscrew' appearance seen in only three patients. Gastroesophageal reflux disease (GERD) was diagnosed by pH testing or endoscopy in 41 patients. We did not find any difference between the rate of simultaneous contractions or esophageal amplitude between patients with a leading symptom of dysphagia and those with chest pain. DES is an uncommon motility disorder that often goes unrecognized for years. Physicians should be aware of the clinical heterogeneity of DES and consider motility testing early in the course of unexplained esophageal symptoms. Given the high prevalence of GERD in DES, the role of GERD and the impact of acid-reducing therapy in DES deserve further study.

Systematic review: the treatment of noncardiac chest pain.

BACKGROUND: Treatment of noncardiac chest pain (NCCP) remains a challenge. This is in part due to the heterogeneous nature of this disorder. Several conditions are associated with NCCP including gastro-oesophageal reflux disease (GERD), oesophageal dysmotility, oesophageal hypersensitivity as well as others. AIM: To determine the currently available therapeutic modalities for NCCP. METHODS: We performed a systematic review of the literature that was published between January, 1980 and March, 2011. We identified 734 studies; 68 of them met entry criteria. RESULTS: Patients with GERD-related NCCP should receive proton pump inhibitors (PPI) twice daily for at least 8 weeks. Smooth muscle relaxants are only recommended for temporary relief of NCCP with motility disorders. Botulinum toxin injection of the distal oesophagus may be effective in the treatment of NCCP and spastic oesophageal motility disorders. Studies assessing the value of tricyclic antidepressants, trazodone and selective serotonin reuptake inhibitors in NCCP are relatively small, but suggest an oesophageal analgesic effect in NCCP patients that is limited by their side effects profile. The usage of theophylline to treat patients with non-GERD-related NCCP should be weighed against its potential toxicity. Use of complementary medicine has been scarcely studied in NCCP. Patients with coexisting psychological morbidity or those not responding to any medical therapy should be considered for psychological intervention. Cognitive behavioural therapy and hypnotherapy may be useful in the treatment of NCCP. CONCLUSIONS: Patients with GERD-related noncardiac chest pain should be treated with at least double dose PPI. The primary treatment for non-GERD-related noncardiac chest pain, regardless if oesophageal dysmotility is present, is pain modulators.

Oesophageal eosinophilic infiltration in patients with noncardiac chest pain.

BACKGROUND: Eosinophilic oesophagitis clinically presents with recurrent episodes of dysphagia and food impaction. Recently, we observed patients with noncardiac chest pain and eosinophilic oesophagitis. AIMS: To estimate the prevalence of abnormal eosinophilic infiltration in noncardiac chest pain patients and examine diagnostic utility of demographic, clinical and endoscopic variables to predict eosinophilic oesophagitis. METHODS: Retrospective study of 171 consecutive patients referred for EGD evaluation of noncardiac chest pain. Endoscopic signs consistent with eosinophilic oesophagitis were recorded. The histological findings were grouped as normal: 0-5 eosinophils/high power field (e/hpf), indeterminate: 6-20 e/hpf, and eosinophilic oesophagitis: ≥21 e/hpf. Abnormal eosinophilic infiltration was defined as ≥6 e/hpf. RESULTS: Abnormal eosinophilic infiltrate was noted in 24 patients (14%). Thirteen (8%) had indeterminate counts, while 11 (6%) had eosinophilic oesophagitis. Compared with normal, those with abnormal oesophageal eosinophilic infiltration were more likely to be male (71% vs. 34%, P=0.001), have allergies (29% vs. 12%, P=0.050), have current GER symptoms (42% vs. 18%, P=0.013), rings (54% vs. 22%, P=0.002), furrows (21% vs. 1%, P<0.001) and abnormal eosinophilic oesophagitis findings on endoscopy (67% vs. 32%, P=0.001). Of the 24 abnormal patients, 23 (96%) were either male or had rings, furrows, or white specks. Conversely, 68 of 69 patients (99%) who were female did not have rings, furrows, or white specks, and endoscopy was normal. Eight patients (33%) with abnormal eosinophilic infiltration had a normal endoscopy. CONCLUSIONS: Eosinophilic oesophagitis should be considered in the evaluation of noncardiac chest pain. Our findings suggest that oesophageal biopsies should be obtained particularly in males with recurrent unexplained chest pain, whether endoscopy is normal or abnormal.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux.

Gastro-oesophageal reflux disease (GERD) has been associated with a variety of supra-oesophageal symptoms, including asthma, laryngitis, hoarseness, chronic cough, frequent throat clearing and globus pharyngeus. GERD may be overlooked as the underlying mechanism for these symptoms because typical GERD symptoms may be absent, despite abnormal oesophageal acid exposure. Two basic mechanisms linking GERD with laryngeal symptoms have been proposed: direct contact of gastric acid with the upper airway, in some cases due to micro-aspiration, and a vagovagal reflex triggered by acidification of the distal portion of the oesophagus. Gastro-oesophageal reflux (GER) during sleep is believed to be an important mechanism for the development of supra-oesophageal complications of GERD, such as asthma and idiopathic pulmonary fibrosis (IPF). Several physiological changes during sleep, including prolonged oesophageal acid contact time, decreased upper oesophageal sphincter pressure, increased gastric acid secretion, decreased salivation, decreased swallowing and a decrease in conscious perception of acid, render an individual more susceptible to reflux-induced injury. Supra-oesophageal symptoms often improve in response to aggressive acid-suppressive therapy. However, many unanswered questions remain regarding the appropriate approach to diagnosis and treatment of patients with GERD-related supra-oesophageal symptoms. In this article we review the relationship between supra-oesophageal symptoms and GERD and, where possible, highlight the evidence supporting the role of night-time reflux as a contributing factor to these symptoms.

Successful oesophageal pH monitoring with a catheter-free system.

BACKGROUND: Traditional catheter-based oesophageal pH testing is limited by patient discomfort and the tendency for patients to alter their diet and activities during the study. A catheter-free pH monitoring system (Bravo) designed to avoid these problems has recently become available, but the advantages and limitations of this device have not been fully explored. AIM: To report our initial experience with this new technology. METHODS: The records of consecutive patients undergoing Bravo pH monitoring were reviewed. The squamo-columnar junction was localized endoscopically and the pH capsule was placed 6 cm above this junction. All patients were re-endoscoped immediately following placement to document mucosal attachment. Patients were monitored for 24-48 h and then returned the radiotelemetry recording device. Data were subsequently downloaded to a personal computer. RESULTS: Sixty studies were performed over an 11-month period. In seven of the 60 (12%), the probe did not attach properly, but in six of these a replacement probe was prepared and deployed without difficulty. In one case, the probe could not be attached after two attempts and the procedure was abandoned. During one procedure, the probe was attached to the mucosa at a point 9 cm from the squamo-columnar junction, but a positive test result was obtained. In two cases, the data were not initially retrievable from the recorder, but in one case the manufacturer was able to retrieve the data overnight. Finally, two patients were away from the data recorder for extended periods, resulting in a loss of data, in two cases, but there was sufficient information for interpretation in both studies. Therefore, adequate diagnostic data were obtained in 58 of the 60 (97%) studies. CONCLUSIONS: Catheter-free pH testing is a major advance in patient convenience and comfort. The technical difficulties associated with this new technology are minimal and appear to be no more frequent than those seen with catheter-based systems.

Are manometric parameters of the upper esophageal sphincter and pharynx affected by age and gender?

The effects of age and gender on the upper esophageal sphincter's (UES) and pharyngeal manometric parameters were investigated in 84 healthy subjects (45 men, 39 women, mean age = 44 years, range = 18-91). Manometric recordings were performed with solid-state circumferential transducers. Subjects older than 60 years (n = 23) showed a significant lower UES resting pressure. In addition, during water swallows they had a higher UES residual pressure, shorter UES relaxation interval and UES relaxation duration, and a decreased UES relaxation rate. Furthermore, pharyngeal contraction had significant higher amplitude and longer duration in subjects older than 60 years during water swallows. Some of these findings were also observed during cookie and pudding swallows. Women had a higher UES resting pressure and a longer UES relaxation interval than men. The observed changes with increasing age indicate loss of basal tone and decreased compliance of the UES. Increased pharyngeal contraction amplitude and its prolonged duration in the elderly might be compensatory to this. These physiologic effects of age and gender on UES and pharyngeal parameters should be taken into account during analysis of manometric studies.

Lichen planus involving the esophagus.

Lichen planus is a common mucocutaneus disorder that rarely involves the esophagus. We report two challenging cases presenting with recurrent dysphagia originally suspected due to gastroesophageal reflux. Subsequent evaluation revealed peculiar endoscopic findings of desquamative esophagitis leading to the diagnosis of lichen planus of the esophagus. This disorder should be considered in middle age or elderly women presenting with unexplained dysphagia or odynophagia. In this paper we review the available literature on the subject and summarize every case reported to date.

Rationale for surgical therapy of Barrett esophagus.

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.