Gender,medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

Background:High-resolution esophageal manometry(HREM)is the diagnostic test of choice for evaluation of nonobstructive dysphagia.Studies regarding the predictors of esophageal dysmotility are limited.Therefore,our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.Methods:We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015.After obtaining IRB approval(16–051),clinical records were scrutinized for demographic data,symptoms,medication use,upper endoscopic findings and esophageal pH findings.HREM plots were classified per Chicago Classification version 3.0.Primary outcome was prevalence of esophageal motility disorders;secondary outcomes assessed predictive factors.Results:In total,155 patients with non-obstructive dysphagia(55616 years old,72%female)were identified.HREM diagnosis was normal in 49%followed by ineffective esophageal motility in 20%,absent contractility in 7.1%,achalasia type II in 5.8%,outflow obstruction in 5.2%,jackhammer esophagus in 4.5%,distal esophageal spasm in 3.9%,fragment peristalsis in 1.9%,achalasia type I in 1.9%,and achalasia type III in 0.6%.Men were five times more likely to have achalasia than women[odds ratio(OR)5.3,95%confidence interval(CI):2.0–14.2;P=0.001].Patients with erosive esophagitis(OR 2.9,95%CI:1.1–7.7;P=0.027)or using calcium channel blockers(OR 3.0,95%CI:1.2–7.4;P=0.015)were three times more likely to have hypomotility disorders.Conclusion:From this study,we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49%of patients with non-obstructive dysphagia.Male gender,erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility:A systemic review and metaanalysis

BACKGROUND Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility.Recently,triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.AIM To compare traditional triangular tip knife and water jet knife in terms of procedural success,duration,instrument exchanges,coagulation forceps use,and adverse events.METHODS We conducted a systemic review and meta-analysis with two authors independently in electronic databases(PubMed,Embase,and Cochrane Library)from inception through May 2021.In addition,we conducted a relevant search by Reference Citation Analysis(RCA)(https://www.referencecitationanalysis.com).A fixed-effects model was used to calculate weighted mean,odds ratio(OR),and confidence intervals(CI).RESULTS We included 7 studies involving 558 patients.Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78(95%CI=0.22-102.47)and odds of clinical success with ratio of 0.93(95%CI=0.29-2.97),respectively.Water jet knife had fewer instrument exchanges compared to triangular knife(2.21,95%CI=1.98-2.45 vs 11.9,95%CI=11.15-12.70)and usage of coagulation forceps(1.75,95%CI=1.52-1.97 vs 2.63,95%CI=2.37-2.89).Adverse events were higher in triangular knife group(OR:2.30,95%CI=1.35-3.95).CONCLUSION Peroral endoscopic myotomy using water jet knife is comparable in terms of pro cedural success to triangular tip knife.Water jet knife also required shorter procedural duration,less instrument exchanges,coagulation devices,and overall adverse events.

Oesophageal surgery

INTRODUCTIONThe origins of oesophageal surgery ,like most surgical treatments ,are based in the treatment of traumatic injury .The Smith Surgical Papyrus describes the examination, diagnosis and treatment of 'a gaping wound of throat, penetrating the gullet' [1].

Manometric findings in patients with isolated distal gastroesophageal reflux

AIM： To analyze manometric abnormalities in patients with isolated distal reflux and compare these findings in patients with erosive and non-erosive disease, METHODS： Five hundred and fifty patients who presented to the outpatient clinic of Turkiye Yuksek Ihtisas Hospital with gastroesophageal reflux disease-like symptoms were enrolled, Each individual was evaluated with esophageal manometry, 24-h ambulatory pH monitoring, and upper gastrointestinal endoscopy, Manometric findings for the patients with isolated distal reflux were compared to findings in controls who were free of reflux disorders or hypersensitive esophagus, Findings for isolated distal reflux patients with and without erosive reflux disease were also compared, RESULTS： Of the 550 subjects enrolled, 97 （17.6%, mean age 48 years） had isolated distal reflux and i00 had no abnormalities on ambulatory pH monitoring （control group, mean age 45 years）. There were no significant differences between the isolated distal reflux group and control group with respect to age, body mass index, and esophageal body contraction amplitude （EBCA）. Mean lower esophageal sphincter pressure was significantly higher in the control group （12.7 ± 10.3 mmHg vs 9.6 ± 7.4 mmHg, P = 0.01）. Fifty-five （56.7%） of the 97 patients with isolated distal reflux had erosive reflux disease. There were no statistical differences between the erosive reflux disease and non-erosive reflux disease subgroups with respect to mean EBCA, lower esophageal sphincter pressure, or DeMeester score.However, 13% of patients with gastroesophageal reflux disease had distal wave amplitudes ≤ 30 mmHg, whereas none of the patients with non-erosive reflux disease had distal wave amplitudes in this low category. CONCLUSION： Patients with erosive and non-erosive disease present with similar manometric abnormalities. The only striking difference is the observation of very low EBCA exclusively in patients with erosive disease.

Dysphagia,reflux and related sequelae due to altered physiology in scleroderma

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement,commonly in the esophagus.Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility.However,there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia.The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition,as well as by xerostomia.In the pharyngeal phase of swallowing,pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance.The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility.However,it can also be affected by obstruction from chronic reflux changes,pill-induced esophagitis,or Candida esophagitis.Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis.Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates

BACKGROUND The critical diagnostic criteria for esophagogastric junction outflow obstruction(EGJOO)were published in the latest Chicago Classification version 4.0(CCv4.0).In addition to the previous criterion[elevated integrated relaxation pressure(IRP)in supine position],manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure.However,with the diagnostic criteria modification,the change in manometric features of EGJOO remained unclear.AIM To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.METHODS We performed a retrospective analysis of 370 patients who underwent highresolution manometry with 5 mL water swallows×10 in supine,×5 in upright position and the rapid drink challenge(RDC)with 200 mL water from November 2016 to November 2021 at Peking University First Hospital.Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled,with 24 patients meeting the updated manometric EGJOO diagnosis(CCv4.0)as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group(either normal median IRP in upright position or less than 20%of supine swallows with elevated IBP).Forty-six patients with normal manometric features were collected as the normal high-resolution manometry(HRM)group.Upper esophageal sphincter(UES),esophageal body,and lower esophageal sphincter(LES)parameters were compared between groups.RESULTS Compared with the normal HRM group,patients with EGJOO(CCv4.0)had significantly lower proximal esophageal contractile integral(PECI)and proximal esophageal length(PEL),with elevated IRP on RDC(P<0.05 for each comparison),while isolated supine IRP elevated patients had no such feature.Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients,including higher LES resting pressure(LESP),intrabolus pressure,median supine IRP,median upright IRP,and IRP on RDC(P<0.05 for each comparison).Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP.Further multivariate analysis revealed that PEL,LESP,and IRP on RDC are factors associated with EGJOO.The receiver-operating characteristic analysis showed UES nadir pressure,PEL,PECI,LESP,and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.CONCLUSION Based on CCv4.0,patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus.Additionally,several parameters are supportive for confirming the diagnosis of EGJOO.

Current clinical approach to achalasia

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and conf irmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients' characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.

Therapeutic efficacy observation of acupuncture plus medicine for laryngopharyngeal reflux due to liver-qi stagnation and spleen deficiency

Objective To observe the clinical efficacy of acupuncture plus medicine in treating laryngopharyngeal reflux due to liverqi stagnation and spleen deficiency.Methods A total of 70 patients were divided into a control group and an observation group by the random number table method,with 35 cases in each group.Both groups were treated with conventional medications,and the observation group was treated with additional acupuncture therapy.The reflux symptom index(RSI)and reflux finding score(RFS)were evaluated.Esophageal motility indicators such as lower esophageal sphincter pressure(LESP)and upper esophageal sphincter pressure(UESP),and salivary pepsin level were measured.The clinical efficacy was also compared.Results The total effective rate of the observation group was higher than that of the control group(P<0.05).After treatment,the RSI and RFS scores in both groups decreased significantly(all P<0.05),and the RSI and RFS scores in the observation group were significantly lower than those in the control group(both P<0.05).There were no significant changes in the LESP and UESP in the control group(both P>0.05),while LESP and UESP in the observation group increased significantly(both P<0.05),and higher than those in the control group(both P<0.05).The salivary pepsin levels in both groups decreased(both P<0.05),and the salivary pepsin level in the observation group was significantly lower than that in the control group(P<0.05).Conclusion Acupuncture plus medicine can improve symptoms and signs in patients with laryngopharyngeal reflux due to liver-qi stagnation and spleen deficiency,and regulate esophageal motility and salivary pepsin level.Its efficacy is more significant compared with medicine alone.