Esophagogastric Junction Contractile Integral (EGJ-CI) in Various Phenotypes of Gastroesophageal Reflux Disease (GERD)

Introduction: Two parameters of high-resolution esophageal manometry are used to observe the function of the esophagogastric junction (EGJ): the anatomical morphology of the EGJ and contractile vigor, which is evaluated with the esophagogastric junction contractile integral (EGJ-CI). To date, how these parameters behave in different gastroesophageal reflux disease (GERD) phenotypes has not been evaluated. Materials and methods: An analytical observational study evaluated patients with GERD confirmed by pH-impedance testing and endoscopy undergoing high-resolution esophageal manometry. The anatomical morphology of the EGJ and EGJ-CI was assessed and compared between reflux phenotypes: acid, non-acid, erosive, and non-erosive. Results: 72 patients were included (63% women, mean age: 54.9 years), 81.9% with acid reflux and 25% with erosive esophagitis. In the latter, a decrease in EGJ-CI (median: 15.1 vs. 23, p = 0.04) and a more significant proportion of patients with type IIIa and IIIb EGJ (83.3% vs 37.1%, p < 0.01) were found. No significant differences existed in the manometric parameters of patients with and without acid and non-acid reflux. Conclusion: In our population, EGJ-CI significantly decreased in patients with erosive GERD, suggesting that it could be used to predict this condition in patients with GERD. This finding is also related to a higher proportion of type III EGJ and lower pressure at end-inspiration of the lower esophageal sphincter in this reflux type.

Introducción: Para observar la función de la unión esofagogástrica (UEG) se utilizan dos parámetros de la manometría esofágica de alta resolución: la morfología anatómica de la UEG y el vigor contráctil, el cual se evalúa con la integral de contractilidad distal de la unión esofagogástrica (IC-UEG). Hasta el momento, no se ha evaluado cómo se comportan estos parámetros en los diferentes fenotipos de enfermedad por reflujo gastroesofágico (ERGE). Metodología: Estudio observacional analítico en el que se evaluaron pacientes con ERGE confirmado por pH-impedanciometría y endoscopia, llevados a manometría esofágica de alta resolución. Se evaluó la morfología anatómica de la UEG y la IC-UEG, y se comparó entre los diferentes fenotipos de reflujo: ácido, no ácido, erosivo y no erosivo. Resultados: Se incluyó a 72 pacientes (63% mujeres, edad media: 54,9 años), 81,9% con reflujo ácido y 25% con esofagitis erosiva. En este último grupo se encontró una disminución de la IC-UEG (mediana: 15,1 frente a 23, p = 0,04) y una mayor proporción de pacientes con UEG tipo IIIa y IIIb (83,3% frente a 37,1%, p < 0,01). No se encontraron diferencias significativas en los parámetros manométricos de los pacientes con y sin reflujo ácido y no ácido. Conclusión: En nuestra población, la IC-UEG estuvo significativamente disminuida en los pacientes con ERGE erosivo, lo que sugiere que podría ser utilizada como un predictor de esta condición en pacientes con ERGE. Este hallazgo también se relaciona con mayor proporción de UGE tipo III y menor presión al final de la inspiración del esfínter esofágico inferior en este tipo de reflujo.

Pictograms to assess bloating and distension symptoms in the general population in Mexico: Results of The Rome Foundation Global Epidemiology Study.

BACKGROUND: There is no term for bloating in Spanish and distension is a very technical word. "Inflammation"/"swelling" are the most frequently used expressions for bloating/distension in Mexico, and pictograms are more effective than verbal descriptors (VDs) for bloating/distension in general GI and Rome III-IBS patients. However, their effectiveness in the general population and in subjects with Rome IV-DGBI is unknown. We analyzed the use of pictograms for assessing bloating/distension in the general population in Mexico. METHODS: The Rome Foundation Global Epidemiology Study (RFGES) in Mexico (n = 2001) included questions about the presence of VDs "inflammation"/"swelling" and abdominal distension, their comprehension, and pictograms (normal, bloating, distension, both). We compared the pictograms with the Rome IV question about the frequency of experiencing bloating/distension, and with the VDs. KEY RESULTS: "Inflammation"/"swelling" was reported by 51.5% and distension by 23.8% of the entire study population; while 1.2% and 25.3% did not comprehend "Inflammation"/"swelling" or distension, respectively. Subjects without (31.8%) or not comprehending "inflammation"/"swelling"/distension (68.4%) reported bloating/distension by pictograms. Bloating and/or distension by the pictograms were much more frequent in those with DGBI: 38.3% (95%CI: 31.7-44.9) vs. without: 14.5% (12.0-17.0); and in subjects with distension by VDs: 29.4% (25.4-33.3) vs. without: 17.2% (14.9-19.5). Among subjects with bowel disorders, those with IBS reported bloating/distension by pictograms the most (93.8%) and those with functional diarrhea the least (71.4%). CONCLUSIONS & INFERENCES: Pictograms are more effective than VDs for assessing the presence of bloating/distension in Spanish Mexico. Therefore, they should be used to study these symptoms in epidemiological research.

Comparison of the epidemiology of disorders of gut-brain interaction in four Latin American countries: Results of The Rome Foundation Global Epidemiology Study.

BACKGROUND: In Latin America, there are scarce data on the epidemiology of DGBI. The Rome Foundation Global Epidemiology Study (RFGES) Internet survey included 26 countries, four from Latin America: Argentina, Brazil, Colombia, and Mexico, with a 40.3% prevalence of Rome IV DGBI. We aimed at comparing the prevalence of DGBI and associated factors among these countries. METHODS: The frequency of DGBI by anatomical region, specific diagnoses, sex, age, diet, healthcare access, anxiety, depression, and HRQOL, were analyzed and compared. RESULTS: Subjects included Argentina n = 2057, Brazil = 2004, Colombia = 2007, and Mexico = 2001. The most common DGBI were bowel (35.5%), gastroduodenal (11.9%), and anorectal (10.0%). Argentina had the highest prevalence of functional diarrhea (p = 0.006) and IBS-D; Brazil, esophageal, gastroduodenal disorders, and functional dyspepsia; Mexico functional heartburn (all <0.001). Overall, DGBI were more common in women vs. men and decreased with age. Bowel disorders were more common in the 18-39 (46%) vs. 40-64-year (39%) groups. Diet was also different between those with DGBI vs. those without with subtle differences between countries. Subjects endorsing criteria for esophageal, gastroduodenal, and anorectal disorders from Mexico, more commonly consulted physicians for bowel symptoms vs. those from Argentina, Brazil, and Colombia. General practitioners were the most frequently consulted, by Mexicans (50.42%) and Colombians (40.80%), followed by gastroenterologists. Anxiety and depression were more common in DGBI individuals in Argentina and Brazil vs. Mexico and Colombia, and they had lower HRQOL. CONCLUSIONS: The prevalence of upper and lower DGBI, as well as the burden of illness, psychological impact and HRQOL, differ between these Latin American countries.

Megaesófago como complicación de acalasia: reporte de caso y revisión narrativa de la literatura / Megaesophagus as a complication of achalasia: Case report and narrative literature review

Resumen El megaesófago se presenta entre el 5 % y el 20 % de pacientes con acalasia, un trastorno motor esofágico primario reconocido hace más de 300 años, a considerarse en todo paciente con disfagia no explicada por un proceso obstructivo o inflamatorio luego de un estudio endoscópico detallado. Se presenta el caso de un paciente con disfagia progresiva, en quien se documentó megaesófago como complicación de una acalasia de largo tiempo de evolución, no tratada. Se descartó la enfermedad de Chagas mediante enzimoinmunoensayo (ELISA) e inmunofluorescencia indirecta (IFI), tal como recomiendan las guías actuales. Ante la baja frecuencia de esta entidad en nuestro medio y las implicaciones terapéuticas que tiene para los pacientes con acalasia, se realizó una revisión narrativa en la literatura sobre su diagnóstico y alternativas de manejo.

Abstract Megaesophagus occurs in between 5% and 20% of patients with achalasia. It is a primary esophageal motor disorder that has been known for more than 300 years. It should be considered in all patients with dysphagia that is not explained by an obstructive or inflammatory process after a detailed endoscopic study. The following is the case of a patient with progressive dysphagia, in whom megaesophagus was documented as a complication of untreated, long-standing achalasia. Chagas disease was ruled out by enzyme immunoassay (ELISA) and indirect immunofluorescence (IF), as recommended by current guidelines. Given the low frequency of this entity in our environment and the therapeutic implications for patients with achalasia, a narrative literature review was carried out to describe its diagnosis and treatment alternatives.

[Endoscopic dilatation in a patient with achalasia during pregnancy: case report and review of the literature]. / Dilatación endoscópica en paciente con acalasia durante el embarazo: reporte de caso y revisión de la literatura.

Achalasia in pregnancy is an infrequent, poorly understood condition and its treatment is not clearly defined. The repercussions on the patients nutritional status are serious and in a pregnant woman have serious implications for the course of gestation, with high risk of intrauterine growth restriction, preterm delivery and even fetal loss; there are symptoms that can be confused with hyperemesis gravidarum delaying the diagnosis. The therapeutic options are medical treatment, endoscopic and surgical interventions; to decide what is the best treatment, we should be taken into account the severity, gestational age and patient conditions. Within the spectrum mentioned in the management include calcium antagonists and nitrates, however these have restrictions in pregnancy, another options are botulinum toxin, endoscopic pneumatic dilation, laparoscopic Heller myotomy and recently POEM. In pregnancy there is a few evidence in the literature and in this moment there are about 40 reported cases, some with complications such as fetal loss and maternal death. We present our experience at the San Ignacio University Hospital in Bogotá, Colombia, with a 26-year-old woman with a novo diagnosis of achalasia type II during the first trimester of pregnancy, with a clinical history of severe dysphagia associated with malnutrition. She was management with enteral nutrition support with nasogastric tube to achieve repletion of the body mass index (BMI) and after that, she had a endoscopic management with Rigiflex balloon dilation. It allowed to successfully carry out pregnancy without adverse effects on the mother or the fetus, with adequate evolution and oral tolerance without dysphagia. We consider that nutritional support is important prior to taking a desicion with this type of patient, in addition that endoscopic management with balloon dilation can be safe and effective for the management of achalasia in pregnancy.

Dilatación endoscópica en paciente con acalasia durante el embarazo: reporte de caso y revisión de la literatura / Endoscopic dilatation in a patient with achalasia during pregnancy: case report and review of the literature

La acalasia en el embarazo es una condición infrecuente, pobremente conocida y su manejo no esta claramente definido. Las repercusiones sobre el estado nutricional de los pacientes con esta entidad son graves y en una gestante tienen implicaciones serias para el curso de la gestación, con riesgo elevado de restricción del crecimiento intrauterino, parto pretérmino e incluso pérdida fetal; existen síntomas que pueden confundirse con hiperémesis gravídica retrasando el diagnóstico. Dentro de las opciones terapéuticas está el manejo médico, endoscópico e intervenciones quirúrgicas; para decidir cual es tratamiento adecuado se debe tener en cuenta la severidad, edad gestacional y condicien clasificaci de teratogenicidad conocido siendo su uso bienestar del binomioones del paciente, dentro del espectro mencionado en el manejo se incluyen los calcioantagonistas y nitratos, estos con restricciones en el embarazo, además toxina botulínica, dilatación neumática endoscópica, miotomía laparoscópica de Heller y recientemente el POEM; estas últimas con riesgo elevado de complicaciones. En el embarazo existe poca evidencia en la literatura y alrededor de 40 casos reportados, algunos con complicaciones como perdida fetal y muerte materna. Presentamos nuestra experiencia en el Hospital Universitario San Ignacio, Bogotá, Colombia de una mujer de 26 años de edad con diagnóstico de acalasia tipo 2 de novo durante el primer trimestre de gestación, cuadro clínico de disfagia severa asociado a desnutrición, a quien el manejo oportuno con soporte nutricional enteral con sonda nasogástrica para lograr repleción del índice de masa corporal (IMC) y luego de esto manejo endoscópico con dilatación con balón. Permitió llevar con éxito a término la gestación sin efectos adversos sobre la madre o el feto, con evolución adecuada y tolerancia a vía oral sin disfagia. Consideramos que es importante el soporte nutricional previo a la toma de conducta con este tipo paciente, además que el manejo endoscópico con dilatación puede ser seguro y efectivo a mediano plazo para el manejo de acalasia en embarazo.

Achalasia in pregnancy is an infrequent, poorly understood condition and its treatment is not clearly defined. The repercussions on the patients nutritional status are serious and in a pregnant woman have serious implications for the course of gestation, with high risk of intrauterine growth restriction, preterm delivery and even fetal loss; there are symptoms that can be confused with hyperemesis gravidarum delaying the diagnosis. The therapeutic options are medical treatment, endoscopic and surgical interventions; to decide what is the best treatment, we should be taken into account the severity, gestational age and patient conditions. Within the spectrum mentioned in the management include calcium antagonists and nitrates, however these have restrictions in pregnancy, another options are botulinum toxin, endoscopic pneumatic dilation, laparoscopic Heller myotomy and recently POEM. In pregnancy there is a few evidence in the literature and in this moment there are about 40 reported cases, some with complications such as fetal loss and maternal death. We present our experience at the San Ignacio University Hospital in Bogotá, Colombia, with a 26-year-old woman with a novo diagnosis of achalasia type II during the first trimester of pregnancy, with a clinical history of severe dysphagia associated with malnutrition. She was management with enteral nutrition support with nasogastric tube to achieve repletion of the body mass index (BMI) and after that, she had a endoscopic management with Rigiflex balloon dilation. It allowed to successfully carry out pregnancy without adverse effects on the mother or the fetus, with adequate evolution and oral tolerance without dysphagia. We consider that nutritional support is important prior to taking a desicion with this type of patient, in addition that endoscopic management with balloon dilation can be safe and effective for the management of achalasia in pregnancy.