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Megaoesophagus resulting from achalasia is a rare but serious cause of airway obstruction. The exact aetiology remains unclear. Achalasia normally presents as weight loss, dysphasia and regurgitation but frequently considerable oesophageal distension can occur without complain and very rarely cause of achalasia presents with stridor or respiratory distress. The authors presents a 19 -year old young lady who had respiratory symptoms and had been treated as a cause of chronic asthma, was found by us to have oesophagus achalasia. She had complained of cough, dispneia and had a pulmonary function studies that showed a severe airway obstruction. After surgery the symptoms disappeared and she had a marked improvement in the flow-volume curve. Oesophagus achalasia should be considered as one of the differential diagnoses of airway obstruction.
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PMID:[Oesophagus achalasia: differencial diagnosis of asthma]. 1836 27

For many patients after subtotal esophagectomy and gastric pull-up, reflux of gastric contents to the esophageal stump is the leading clinical problem. Besides symptoms such as heartburn and regurgitation, de novo formation of columnar mucosa in the esophageal remnant is a well-known and frequent phenomenon. In this context, the remnant supra-anastomotic esophagus serves as an in vivo model for the study of Barrett's carcinogenesis. We present a retrospective case analysis of a patient who developed de novo Barrett's metaplasia followed by de novo invasive carcinoma 28 months after gastric pull-up by assessing clinical and molecular parameters.
Dis Esophagus 2008
PMID:Adenocarcinoma developing in de novo Barrett's mucosa in the remnant esophagus after esophagectomy: clinical and molecular assessment. 1843 96

The aim of this study was to evaluate the effectiveness of floppy Nissen fundoplication with intraoperative esophageal manometry. Between February 1992 and July 2004, there were 102 patients with sliding hiatal hernia undergoing transabdominal Nissen fundoplication. They were divided into three groups: 27 patients were in the Nissen group (CNF), 44 in the floppy Nissen group (FNF, including 5 with laparoscopic Nissen fundoplication), and 31 in the intraoperative-esophageal-manometry group (INF, 13 with laparoscopic Nissen fundoplication). There were no operation-related deaths. Operation-related complications occurred in five patients within 1 month after operation: In CNF, two patients suffered from dysphagia and one from regurgitation; in FNF, one patient had slight dysphagia and two had regurgitation; in INF, there was no one who complained about dysphagia or regurgitation, but pneumothorax occurred in one case. After more than 2 years of follow-up, two patients, in CNF, suffered from severe dysphagia, one recurred and two with abnormal 24 h pH monitoring. In FNF, one patient had dysphagia, one recurred and three had abnormal 24 h pH monitoring; in INF, two patients had acid reflux on 24 h pH monitoring. The postoperative lower esophageal sphincter pressure was in the normal range in 30 of 31 patients (96.5%). The normal rate of postoperative tests in CNF, FNF and INF were 81.5%, 86.4% and 93.5%, respectively. Both the Nissen fundoplication and the floppy Nissen fundoplication are effective approaches to treat patients with sliding hiatal hernia. Intraoperative manometry is useful in standardizing the tightness of the wrap in floppy Nissen fundoplication and may contribute to reducing or avoiding the occurence of postoperative complications.
Dis Esophagus 2008
PMID:Outcome of floppy Nissen fundoplication with intraoperative manometry to treat sliding hiatal hernia. 1847 60

The prevalence of gastroesophageal reflux disease (GERD) in China is lower than that in the Western countries, but appears to be increasing. The aim of this pilot study was to evaluate the prevalence of GERD in Shanghai, China, and to explore which population characteristics where associated with GERD. A sample of 1200 adult inhabitants of Shanghai, selected using randomized, stratified, multi-stage sampling, completed Mandarin translations of the Reflux Disease Questionnaire and GERD Impact Scale. Potential risk factors for GERD were examined by nested case-control analysis, using Cochran-Armitage trend testing and logistic regression analysis. The response rate was 86.2%; 919 responses were suitable for analysis. The prevalence of GERD, defined as heartburn and/or regurgitation of any frequency during the previous week, was 6.2% in Shanghai. Obesity and urban dwelling were associated with GERD (odds ratio 3.4, 95% confidence interval 1.3-9.3; and odds ratio 3.6, 95% confidence interval 1.2-10.4, respectively). The prevalence of GERD in Shanghai agreed with previous Chinese studies. GERD in Shanghai was associated with obesity and residency in an urban environment.
Dis Esophagus 2009
PMID:Prevalence of, and factors associated with, gastroesophageal reflux disease: a population-based study in Shanghai, China. 1920 45

Collis gastroplasty with fundoplication is an accepted treatment for gastroesophageal reflux disease (GERD) complicated by short esophagus. The procedure can be done either via left thoracotomy or using minimally invasive laparoscopic techniques. Few centers have reported long-term follow-up for patients undergoing a Collis gastroplasty using both the open and minimal access techniques. Retrospective review of prospectively collected data at Creighton University was done to identify patients who underwent Collis gastroplasty with fundoplication for GERD. After approval from the institutional review board, the patients were contacted and administered a questionnaire regarding symptoms and satisfaction. Data were entered in a dataset and analyzed from the patient's perspective. Eighty-five patients underwent a Collis gastroplasty procedure over a period of 13 years. Forty-eight percent (41 cases) were performed laparoscopically, and a transthoracic open repair was performed in the rest. Long-term data (more than 9 months) was available on 52 patients. Surgery resulted in complete resolution of heartburn, chest pain, regurgitation, and dysphagia in 52, 22, 54, and 29% of patients, respectively. More than 75% of the patients were satisfied with the outcome of surgery, and more than 85% would recommend the procedure to another patient. Collis gastroplasty with fundoplication results in good long-term patient satisfaction and symptom control.
Dis Esophagus 2009
PMID:Long-term symptomatic outcomes after Collis gastroplasty with fundoplication. 1922 32

Twenty-four-hour multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring detects both acid and nonacid gastroesophageal reflux episodes. The MII-pH catheter contains six impedance segments placed 3, 5, 7, 9, 15, and 17 cm above the lower esophageal sphincter (LES). A pH electrode at 5 cm above the LES identifies the type of reflux, i.e. acid or nonacid. Patients with acid and nonacid reflux exhibit typical and atypical symptoms often within 5 min following a reflux episode. The aim of this study is to compare the timing of symptoms after reflux episodes in patients with acid and nonacid reflux. Methods include a review of 70 MII-pH tracings (42 females, mean age 40, range 18-85 years) either on (50 points) or off (20 points) acid suppression therapy. Typical (heartburn, regurgitation) and atypical (cough) symptoms with acid or nonacid reflux episodes detected by impedance were analyzed. Symptoms were considered positive with acid reflux if there was a pH drop to <4, plus an MII detected a reflux episode and with nonacid reflux if pH remained >4 and MII detected a reflux episode. The timing of the symptom after each reflux episode was recorded. Symptom perception occurred significantly sooner after acid versus nonacid reflux (P < 0.05). Acid reflux episodes are more likely to be perceived in the first 2 min following the reflux episode. Patients with acid reflux are likely to perceive symptoms earlier, and symptoms with acid and nonacid reflux may be produced by different mechanisms.
Dis Esophagus 2009
PMID:Symptoms with acid and nonacid reflux may be produced by different mechanisms. 1922 35

Eosinophilic esophagitis (EoE) is increasingly being diagnosed in adults presenting with dysphagia, food impactions, and chest pain. Studies to date provide conflicting data on the association of EoE and esophageal dysmotility. The objective of this study was to evaluate the prevalence of esophageal dysmotility in a cohort of patients with biopsies consistent with EoE at a military treatment facility. This is a prospective evaluation of consecutively identified patients at our institution diagnosed with EoE from March 1, 2005 to June 1, 2007. Thirty-two patients with biopsies consistent with EoE completed a symptom survey and 30 underwent esophageal manometry. The majority of EoE patients (23/30, 77%) had a normal end-expiratory lower esophageal sphincter (LES) pressure (normal range 10-35), whereas six patients had a low-normal LES pressure (6-9 mm Hg) and one patient had a decreased LES pressure (<5 mm Hg). Five patients (15.6%) were diagnosed with a nonspecific esophageal motor disorder (NSEMD). Two patients had high mean esophageal amplitude contractions >180 mm Hg (188 mm Hg, 209 mm Hg). No patient was diagnosed with nutcracker esophagus or diffuse esophageal spasm. Patients with and without NSEMD reported a similar degree of swallowing difficulty, heartburn, belching, chest pain, regurgitation, symptoms at night, and total symptom score. Likewise, eosinophil count on mucosal biopsy was similar between patients with and without a NSEMD. In this cohort, we found the prevalence of an NSEMD to be similar to that of a 10% prevalence found in a gastroesophageal reflux population.
Dis Esophagus 2009
PMID:Prevalence of esophageal dysmotility in a cohort of patients with esophageal biopsies consistent with eosinophilic esophagitis. 1930 12

The clinical significance of nonspecific esophageal motility disorder (NEMD) is unclear. Our aim was to investigate the natural history of NEMD. All manometries performed at Meir Hospital from 1997 to 2004 and diagnosed as NEMD were reviewed. Manometric criteria for NEMD included either low-amplitude peristalsis, nonprogression of peristalsis, prolonged retrograde or triple-peaked waves, or incomplete relaxation of the lower sphincter. Patients determined to have NEMD were contacted and asked to complete a questionnaire and undergo a second manometry. NEMD had been diagnosed in 137 patients. Upon review of manometry results, 65 patients were eligible for the study (36 men and 29 women). The other 72 patients did not have NEMD when we reviewed their manometry tracing, applying strict criteria as specified in Table 1. The average age was 64 +/- 16 years (range 24-83 years). The average follow-up period was 7 +/- 2 years. All 65 patients were symptomatic at their initial prestudy visit. By the second visit, symptoms had resolved in 33 (51%) patients and improved in 13 (19%). Dysphagia, chest pain, and food regurgitation had improved, whereas heartburn and respiratory symptoms had not. Of 37 patients with triple-peaked waves, only 11 (30%) had improved clinically. Of the 65 study patients, 17 (26%) had a second manometry during the study, which was normal in 2 (12%), unchanged in 11 (69%), and revealed achalasia in 4 (23%), representing 6% of all study patients. NEMD is generally a benign disorder that improves clinically in most cases. Nevertheless, in about 6% of patients, NEMD may evolve into achalasia.
Dis Esophagus 2009
PMID:Nonspecific esophageal motility disorders may be an early stage of a specific disorder, particularly achalasia. 1930 17

Intraluminal high dose rate brachytherapy (ILHDR BT) is one of several effective modalities for palliation of advanced esophageal cancer. Thirty patients with endoscopic-proven, mostly locally advanced, squamous cell carcinoma of the esophagus, not involving the gastroesophageal junction and without distant metastases, were included in this analysis. Twenty-nine patients received two ILHDR BT sessions of 8 Gy within a week and one patient received only one session. All patients were followed monthly. Outcomes included quality of life (QOL), symptoms control: dysphagia, regurgitation, odynophagia, and chest or back pain, as well as, overall survival. Through 4 months of follow-up, QOL was statistically improved (having lowered scores) in regards to feelings (P= 0.013), sleeping (P= 0.032), eating (P= 0.020), and social life (P= 0.002). The most significantly improved symptom was dysphagia (P < 0.006), with a reduction of 0.52 units or one-half grade. Regurgitation, odynophagia, and pain were lower during follow-up but were not statistically significant. The median overall survival from death of any cause was 165 days (with a 95% confidence interval of 128-195 days). In conclusion, ILHDR BT of advanced squamous esophageal cancer consisting of two out-patient procedures is very successful in achieving the primary objectives of the patients to reduce dysphagia and improve QOL.
Dis Esophagus 2009
PMID:Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus. 1930 21

The inlet patch is an area of heterotopic gastric mucosa most commonly located in the postcricoid portion of the esophagus at, or just below, the level of the upper esophageal sphincter. Esophageal and supraesophageal symptoms are commonly associated with inlet patch, while esophageal adenocarcinoma rarely complicates it. Laryngeal adenocarcinoma associated with inlet patch is not described in the literature. Herein, we present the first reported case of inlet patch associated with laryngeal carcinoma. A 33-year-old female with long-standing asthma and presumed gastroesophageal reflux developed laryngeal cancer at age 22 years that was treated with concomitant radiation and induction chemotherapy. Subsequently, she had refractory heartburn, dysphagia, and cough. These symptoms continued despite two Nissen fundoplications, glottic web division, and optimal medical management. Upper endoscopy at our institution revealed an upper esophageal stricture and a 1 cm inlet patch. Biopsies showed columnar mucosa (predominantly gastric cardiac/fundic type) consistent with inlet patch, with focal intestinal metaplasia. Subsequent endoscopic mucosal resection of the inlet patch resulted in an amelioration of throat and chest pain, cough, and hoarseness. Dysphagia and regurgitation were improved by serial dilatations of the upper esophageal stricture. This case reveals a number of clinical findings associated with inlet patch--chest pain, dysphagia, cough, and hoarseness--as well as a clinical finding that has not been previously associated with inlet patch: laryngeal cancer. Symptoms refractory to optimal medical management and/or surgical intervention should make the clinician and endoscopist more cognizant of the inlet patch.
Dis Esophagus 2009
PMID:Heterotopic gastric mucosa (inlet patch) in a patient with laryngopharyngeal reflux (LPR) and laryngeal carcinoma: a case report and review of literature. 1947 8


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