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Query: UMLS:C0014848 (achalasia)
 2,804 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Esophageal dilatation as a treatment option in patients with both benign and malignant esophageal strictures is described. Types of dilators available, techniques of passage, complications, redilation rates, and comparative studies between dilating systems are reviewed. The use of proton pump inhibitors to reduce the rates of redilation is discussed in view of the natural history of benign esophageal strictures. Comparisons among blind passage, fluoroscopic guidance and endoscopically directed dilatation are made and discussed in relation to cost effectiveness. Brief mention of new dilating systems including wall stents and wall-tension-sensing systems are made. Achalasia treatment with pneumatic dilatation is described in detail and compared to medication and surgical myotomy options. New treatments, including botulinum toxin injection into the lower esophageal sphincter, are briefly mentioned.
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PMID:Esophageal dilatation. 859 May 21

Laparoscopic Nissen fundoplication has replaced open approaches for refractory gastroesophageal reflux disease (GERD) in many major medical centers. Here we report our preliminary results of the Belsey Mark IV antireflux procedure performed by video-assisted thoracoscopy (VATS-Belsey). Fifteen patients underwent VATS-Belsey. The indications for surgery included GERD refractory to medical therapy (n=10), achalasia (n=2), diffuse esophageal spasms (n=1), epiphrenic esophageal diverticulum (n=1), and paraesophageal hernia (n=1). The median operative time was 235 min. There were three conversions to open minithoracotomy (8-10 cm) necessitated by severe adhesions (n=2) and repair of a gastric perforation (n=1). The median hospital stay was 4 days. Postoperative complications included persistent air leaks, requiring discharge with a Heimlich valve in one patient. There were no perioperative deaths. At a median follow-up of 19 months, ten patients (66%) were asymptomatic and were not taking any antacids. One patient who had taken proton pump inhibitors preoperatively required postoperative H2 blockers for mild heartburn. In three patients, recurrent GERD symptoms (mean follow-up 6 months) led to laparoscopic takedown of the Belsey and Nissen fundoplication. One patient with achalasia, who had recurrent dysphagia after 1 year of relief following VATS myotomy and Belsey, underwent esophagectomy. The Belsey Mark IV antireflux procedure is technically feasible by VATS with minimal morbidity. However, our preliminary results suggest that open thoracotomy for Belsey Mark IV should remain the standard operation for GERD with poor esophageal motility when a thoracic approach is desired. We have modified our approach to laparoscopic partial fundoplications (Toupet or Dor) for severe GERD and poor esophageal motility when an abdominal approach is possible.
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PMID:Preliminary results of thoracoscopic Belsey Mark IV antireflux procedure. 964 40

Progress in the pharmacotherapy of pediatric gastrointestinal diseases continued during 1998 despite ongoing obstacles encountered by clinicians and researchers. The major change involved warnings that cisapride, a widely used prokinetic agent, could cause potentially fatal arrythmias in susceptible people. The risk for children is unclear and a consensus of prescribing guidelines is needed. Excellent pediatric-oriented reviews have been published that summarize our knowledge of proton pump inhibitors, probiotics, 5-hydroxtryptamine-3 (5-HT3) antagonists, and the treatment of gastrointestinal infections and chronic abdominal pain. Triple medication therapy for the eradication of Helicobacter pylori is now the standard of care, but the optimal combination and duration of therapy needs to be determined. Also described are interesting developments requiring further confirmation: the treatments of infectious diarrhea with zinc; achalasia and Hirschsprung's disease with botulinum toxin; weight loss with megestrol acetate; and sialorrhea with glycopyrollate.
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PMID:Update on medications used to treat gastrointestinal disease in children. 1055 90

Patients with recurrent angina-like chest pain with normal coronary vessels are deemed to have the syndrome of noncardiac chest pain (NCCP). These patients, despite having significant cardiac disease ruled out, often spend a restricted lifestyle believing they have cardiac disease. These recurrent episodes of chest pain may be related to gastroesophageal reflux disease (GERD), spastic motility disorders of the esophagus and esophageal (visceral) hyperalgesia. These disease entities are often difficult to diagnose and treat except for GERD and achalasia. Recent prospective double-blind studies have shown that about 44% of these patients may have underlying GERD. There is now more evidence to support the practice of empiric use of proton pump inhibitors (PPIs) as the first step in therapy. Newer modalities for diagnosis like endoscopic ultrasonography (EUS) showed that this group of patients had sustained muscular contractions of longer that 68 s during chest pain. These sustained contractions noted on EUS were secondary to isometric contraction of the circular muscle which did not cause luminal constriction nor was related to contraction of the longitudinal muscles which cannot be recorded by pressure manometry. Treatment is difficult if patients do not respond to high-dose PPIs. Other medications which are known to alter visceral hyperalgesia in low doses, such as tricyclic antidepressants like imipramine and desyrel, can be tried. Psychological intervention may be useful in the management of some of these patie
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PMID:Update on noncardiac chest pain. 1127 32

Cardiomyotomy is now usually performed using a minimally invasive approach. A consecutive series of 18 patients with an intention to treat thoracoscopically were followed by the same number of patients treated laparoscopically. Both groups have been followed prospectively for a minimum of 2 years. The groups were well matched for age, symptom duration, preoperative lower esophageal sphincter pressure, and number having undergone balloon dilatation. There was one conversion from a thoracoscopic to a laparoscopic approach so that, for the purpose of analysis, there are 17 in the thoracoscopic group and 19 in the laparoscopic group. There was no difference in the average operating time, rate of conversion to open operation, mucosal breaches, or length of hospitalization. Nor was there any difference in dysphagia symptoms, with 14/17 having a satisfactory result after thoracoscopic myotomy and 18/19 after laparoscopic myotomy. Frequency of reflux symptoms was similar and, although mild reflux was common, only two patients required treatment with a proton pump blocker. In the treatment of achalasia, thoracoscopic and laparoscopic myotomy without fundoplication are equally effective in relieving dysphagia and have a similar safety profile.
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PMID:Heller's myotomy: thoracoscopic or laparoscopic? 1128 74

Apart from gastroesophageal reflux disease, achalasia, non-cardiac chest pain and functional dysphagia are the most important manifestations of disturbed esophageal motility. Achalasia is characterized by esophageal aperistalsis and impaired deglutitive relaxation of the lower esophageal sphincter. The morphological correlate is a degeneration of nitrergic neurons in the myenteric plexus. Diagnosis is based on barium esophagram or esophageal manometry with the latter setting the gold standard. Endoscopic exclusion of a tumor at the gastroesophageal junction is mandatory. Appropriate therapeutic interventions are pneumatic dilatation or (laparoscopic myotomy) of lower esophageal sphincter. In patients unfit for these procedures endoscopic injection of botulinum toxin into the lower esophageal sphincter is appropriate. Non-cardiac chest pain may be of esophageal origin. Gastroesophageal reflux, spastic motility disorders and visceral hypersensitivity are arguable underlying mechanisms. The most important diagnostic procedure is 24 h esophageal pH metry correlating symptoms and reflux episodes. Proton pump inhibitors and tricyclic antidepressants serving as visceral analgesics are appropriate therapeutic approaches. Functional dysphagia defines the sensation of impaired passage without mechanical obstruction or a neuromuscular disease with known pathology, e.g. scleroderma. Impaired transit is proven by esophageal scintigraphy or radiogram both using solid boluses. Manometry assesses the underlying mechanisms.
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PMID:[Diagnosis and treatment of esophageal motility disorders]. 1130 49

Non-cardiac-chest-pain is frequently associated with esophageal diseases. Gastroesophageal reflux disease (GERD) is present in 60%, esophageal motility disorder in 40-50%, tumours in 5-10% and achalasia in 5% of such cases. Diagnosis is based on endoscopy and in patients with no endoscopy findings on 24-h esophageal pH-monitoring. GERD can present with various symptoms and can best be managed with proton pump inhibitors (PPI). Considering increased mortality and morbidity operation should only be performed in special situations. Esophageal motility disorders most frequently produce retrosternal pain. Pain in achalasia may not respond to standard therapy. Motility disorders and achalasia are diagnosed by perfusion manometry and videofluoroscopy. If a tumour is suspected diagnosis is made by endoscopy (biopsy, endosonography) and radiology.
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PMID:[Thoracic pain from the viewpoint of the gastroenterologist: diagnosis and therapy]. 1145 75

The basic principle behind the treatment of achalasia consists of alleviating swallowing disorders by reducing resistance in the lower esophageal sphincter without inducing gastroesophageal reflux. Only a few studies are available on long-term results after operative treatment. Fifty-one patients were studied with regard to long-term results after open transabdominal extramucosal myotomy of the distal esophagus along with partial anterior fundoplication (Dor procedure). Clinical data were collected by standardized interviews, and symptoms were assigned a score ranging from 0 to 3 according to severity and frequency. The pre- and postoperative symptoms were comparable in 50 patients. The median duration of follow-up was 88 months (range: 12-160 months). Operative time was a median of 80 min. Two esophageal mucosal tears were recognized intraoperatively and promptly repaired. Postoperative morbidity occurred in two patients (3.9%). Very good or good long-term results after surgical therapy were achieved in 49 patients (96.1%). Forty-seven patients (92.2%) have no or rare dysphagia. The frequency of regurgitation as well as chest pain was also significantly reduced after surgery. Forty-nine patients (96.1%) either maintained or gained weight. Preoperative duration of symptoms, follow-up, age, and gender had no influence on the results (p > 0.05). Two patients (3.9%) mentioned occasional heartburn. Five patients (9.8%) took or still take proton pump inhibitors postoperatively. Severe stage IV symptoms due to peptic stricture and dolichomegaesophagus required reoperation in one patient (2%). The results show that myotomy and the antireflux procedure (semifundoplication) lead to long-term relief of dysphagia without inducing reflux at a low operative risk. Since long-term results are as yet not available for minimally invasive surgery, it remains to be seen if this operative technique will become the primary surgical procedure for this disease.
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PMID:[Long-term outcome of myotomy and semi-fundoplication in achalasia]. 1224 80

Gastroesophageal reflux disease, achalasia and esophageal spasms are the most frequent esophageal motility disorders and are associated with dysphagia and non-cardiac chest pain. The diagnosis of achalasia is based on manometric criteria. Pneumatic dilatation, laparoscopic myotomy, and the minimal invasive injection of botulinum toxin are therapeutic options. Long-term-pH-metry is the gold standard to diagnose gastroesophageal reflux disease. Proton pump inhibitors (PPI) are the first-line therapy in reflux disease. Esophageal manometry and pH-metry are essential investigations prior to an antireflux operation. The evaluation of chronic constipation refractory to medical treatment should include anal manometry, and MR-defecography for the diagnosis of anorectal outlet obstruction such as anismus which could be treated successfully by biofeedback therapy.
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PMID:[Gastrointestinal motility disorders relevant to general practice]. 1242 42

FROM AN ETIOLOGICAL POINT OF VIEW: Thoracic pain is a frequent symptom. Before confirming the oesophageal origin of the pain, a coronary disease must be excluded. Two principle causes are source of thoracic pain of oesophageal origin: gastro-oesophageal reflux disease and oesophageal motility abnormalities. THE DIAGNOSTIC APPROACH: This must include the questioning of the patient and the usual paraclinical examinations. To confirm the diagnosis, these examinations must establish a chronological relationship between the symptoms and the abnormalities. For economic reasons, following a normal gastroscopy, there is a tendency to propose an empirical proton pump inhibitor (PPI) test rather than a 24 hour pH-metry antireflux as first line. The improvement or even the disappearance of the symptoms confirms the diagnosis; long-term treatment with a double dose of PPI should therefore be envisaged. The pH-metry with search for results should be proposed to the non-responders and to patients with atypical reflux manifestations. Dysphagia and odynophagia suggest an oesophageal motility disorder that basal manometry should confirm. A chronological relationship is rarely revealed, but the sensitivity of the pH-meter can be enhanced by provocation tests. REGARDING TREATMENT: Other than achalasia, treatment of the other spastic-like motor disorders is not well codified. Diltiazem is efficient. Some patients exhibit a hyperalgic oesophagus. The physiopathological mechanisms are still theoretical. Low dose tricyclic antidepressors and psychological management are useful.
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PMID:[Thoracic pain of oesophageal origin. Diagnostic management and treatment]. 1471 71


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