Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux

BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant,likely through recurrent aspiration and allograft injury.Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes,the role of esophageal manometry in the assessment of lung transplant patients remains debated,and the impact of esophageal dysmotility on transplant outcomes is unclear.Of particular interest is ineffective esophageal motility(IEM)and its associated impact on esophageal clearance.AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018.Patients with pre-transplant anti-reflux surgery were excluded.Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing.Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection,defined histologically per International Society of Heart and Lung Transplantation guidelines.Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery,last clinic visit,or death.Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.RESULTS Of 184 subjects(54%men,mean age:58,follow-up:443 person-years)met criteria for inclusion.Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis(41%).During the follow-up period,60 subjects(33.5%)developed acute rejection.The all-cause mortality was 16.3%.Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection[hazard ratio(HR):1.984,95%CI:1.03-3.30,P=0.04],confirmed on Kaplan-Meier curve.On multivariable analysis,IEM remained independently associated with acute rejection,even after controlling for potential confounders such as the presence of acid and nonacid reflux(HR:2.20,95%CI:1.18-4.11,P=0.01).Nonacid reflux was also independently associated with acute rejection on both univariate(HR:2.16,95%CI:1.26-3.72,P=0.005)and multivariable analyses(HR:2.10,95%CI:1.21-3.64,P=0.009),adjusting for the presence of IEM.CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation,even after controlling for acid and nonacid reflux.Esophageal motility testing may be considered in lung transplant to predict outcomes.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM:To investigate the relationship between exerciseprovoked esophageal motility disorders and the prognosis for patients with chest pain.METHODS:The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor(PPI).In all,a coronary artery angiography,panendoscopy,24-h esophageal pH-metry and manometry,as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring,were performed.Thirtyfive subjects had no significant coronary artery lesions,and 28 had more than 50% coronary artery narrowing.In patients with hypertensive esophageal motility disorders,a calcium antagonist was recommended.The average follow-up period was 977 ± 249 d.RESULTS:The prevalence of esophageal disorders,such as gastroesophageal reflux or diffuse esophageal spasm,was similar in patients both with and without significant coronary artery narrowing.Exercise prompted esophageal motility disorders,such as a decrease in the percentage of peristaltic and effective contractions and their amplitude,as well as an increase in the percentage of simultaneous and non-effective contractions.In 14(22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%.Using Kaplan-Meier analysis and the proportional hazard Cox regression model,it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period.CONCLUSION:In patients with chest pain non-responsive to PPIs,a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophagealmotility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from nonerosive reflux disease to erosive reflux disease and Barrett's esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease

AIM To investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in nonerosive gastroesophageal reflux disease(GERD)(NERD) patients.METHODS Thirty-six NERD patients with low(< 20 g/d) dietary fiber intake were enrolled in the study. They were examined with the use of symptom questionnaire(GERD-Q), highresolution esophageal manometry, 24-h esophageal p Himpedance examinations, and food frequency questionnaire before and after 10 d of usual diet supplemented by psyllium 5.0 g TID. Complete data of 30 patients were available to the final analysis. The obtained results were analyzed with the use of non-parametric statistics(Wilcoxon matched pairs test). RESULTS The number of patients experiencing heartburn was less(93.3% at baseline vs 40% at the end of the study, P < 0.001) and the GERD-Q score decreased(mean ± SD: 10.9 ± 1.7 vs 6.0 ± 2.3, P < 0.001) after the treatment period. Minimal resting lower esophageal sphincter(LES) pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4 mm Hg(P = 0.023), but no change in residual LES pressure and mean resting pressure was found. Total number of gastroesophageal refluxes(GER) decreased from 67.9 ± 17.7 to 42.4 ± 13.5(P < 0.001) predominantly by acid and weak acid types of GERs. No significant change in mean esophageal p H and % of time p H < 4 was registered. Maximal reflux time decreased from 10.6 ± 12.0 min to 5.3 ± 3.7 min(P < 0.05). CONCLUSION Fiber-enriched diet led to a significant increase of minimal lower esophageal sphincter resting pressure, a decrease of number of gastroesophageal refluxes, and a decrease of heartburn frequency per week in NERD.

Influence of endoscopic submucosal dissection on esophageal motility

AIM: To assess esophageal motility after esophageal endoscopic submucosal dissection (ESD). METHODS: Twelve patients (6 men and 6 women) aged 53-64 years (mean age, 58 years) who underwent regular examination 3-12 mo after esophageal ESD for neoplasms of the esophageal body were included in this study. The ESD procedure was performed under deep sedation using a combination of propofol and fentanyl, and involved a submucosal injection to lift the lesion and use of a dual-knife and an insulated-tip knife to create a circumferential incision around the lesion extending into the submucosa. Esophageal motility was examined using a high-resolution manometry system. Dysphagia was graded using a five-point scale according to the Mellow and Pinkas scoring system. Patient symptoms and the results of esophageal manometry were then analyzed. RESULTS: Of the 12 patients enrolled, 1 patient hadgrade 2 dysphagia, 1 patient had grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Ineffective esophageal motility was observed in 5 of 6 patients with above semi-circumference of resection extension. Of these 5 patients, 1 patient complained of grade 2 dysphagia (with esophageal stricture), one patient complained of grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Normal esophageal body manometry was observed in all 6 patients with below semi-circumference of resection extension. The 6 patients with normal esophageal motility did not complain of dysphagia. CONCLUSION: Extensive esophageal ESD may cause esophageal dysmotility in some patients, and might also have an influence on dysphagia although without esophageal stricture.

Gastrointestinal motility disorders in inflammatory bowel diseases

The relationship between motility and inflammatory gastrointestinal disorders is at the same time complex and intriguing since these conditions might share some genetic, environmental, immunological and microbial predisposing factors. In addition, significant symptom overlapping may occur, muddling the waters within the clinical context. Although on one hand this represents a challenge for the clinician for a potential under- or over-treatment and diagnostic delay, on the other hand it possibly represents an opportunity for the researcher to better disclose the intimate relationship between chronic (often low-grade) inflammation, motor disorders and deranged sensory function. The best example is probably represented by Crohn&#x02019;s disease and ulcerative colitis. In fact, a number of gastrointestinal motor disorders have been described in association with these diseases, disorders which span from the esophagus to the anorectum, and which will be extensively covered in this review. It is conceivable that at least part of this derangement is strictly related to inflammatory cytokine trafficking and neuromuscular changes; however, given the high prevalence of functional gastrointestinal disorders in the general population, this overlap might also be serendipitous. However, it is worth noting that literature data on this topic are relatively scarce, sometimes quite outdated, and mostly focused on the interplay between irritable bowel syndrome and inflammatory bowel disease. Nevertheless, both researchers and clinicians must be aware that symptoms related to gastrointestinal motility disorders may be highly prevalent in both active and inactive inflammatory bowel disease, correlate with greater psychological comorbidity and poorer quality of life, and may negatively influence the therapeutic approaches.

Autonomic functions and gastric motility in children with functional abdominal pain disorders

BACKGROUND Abdominal pain-predominant functional gastrointestinal disorders(AP-FGIDs)are the most common cause of recurrent abdominal pain in children. Despite its high prevalence, the underlying pathophysiology of this condition is poorly understood.AIM To assess the role of gastric dysmotility and autonomic nervous system dysfunction in the pathophysiology of AP-FGIDs.METHODS One hundred children, fulfilling Rome III criteria for AP-FGIDs, and 50 healthy controls, aged 5 to 12 years, were recruited after obtaining parental consent. All patients were investigated for underlying organic disorders. Gastric motility and cardiovascular autonomic functions were assessed using validated non-invasive techniques.RESULTS The main gastric motility parameters assessed(gastric emptying rate [45.7 vs 59.6 in controls], amplitude [48.7 vs 58.2], frequency of antral contractions [8.3 vs 9.4],and antral motility index [4.1 vs 6.4]) were significantly lower in children with AP-FGIDs(P < 0.05). The post-prandial antral dilatation at 1 min after the test meal significantly correlated with the severity of abdominal pain(P < 0.05).Assessment of autonomic functions in AP-FGID patients showed neither a significant difference compared to the control group, nor a correlation with gastric motility abnormalities(P > 0.05). The duration of pain episodes negatively correlated with the parasympathetic tone(maladaptive parasympathetic tone)(P< 0.05).CONCLUSION Children with AP-FGIDs have abnormal gastric motility but normal cardiovascular autonomic functions. There is no relationship between abnormal gastric motility and autonomic functions. The pathogenesis of AP-FGIDs is not related to cardiovascular autonomic dysfunction.

Gastrointestinal motility and absorptive disorders in patients with inflammatory bowel diseases: Prevalence, diagnosis and treatment

Inflammatory bowel diseases(IBD),Crohns disease and ulcerative colitis,are chronic conditions associated with high morbidity and healthcare costs.The natural history of IBD is variable and marked by alternating periods of flare and remission.Even though the use of newer therapeutic targets has been associated with higher rates of mucosal healing,a great proportion of IBD patients remain symptomatic despite effective control of inflammation.These symptoms may include but not limited to abdominal pain,dyspepsia,diarrhea,urgency,fecal incontinence,constipation or bloating.In this setting,commonly there is an overlap with gastrointestinal(GI)motility and absorptive disorders.Early recognition of these conditions greatly improves patient care and may decrease the risk of mistreatment.Therefore,in this review we describe the prevalence,diagnosis and treatment of GI motility and absorptive disorders that commonly affect patients with IBD.

Genetic contribution to motility disorders of the upper gastrointestinal tract

Motility disorders of the upper gastrointestinal tract encompass a wide range of different diseases. Esophageal achalasia and functional dyspepsia are representative disorders of impaired motility of the esophagus and stomach, respectively. In spite of their variable prevalence, what both diseases have in common is poor knowledge of their etiology and pathophysiology. There is some evidence showing that there is a genetic predisposition towards these diseases, especially for achalasia. Many authors have investigated the possible genes involved, stressing the autoimmune or the neurological hypothesis, but there is very little data available. Similarly, studies supporting a post-infective etiology, based on an altered immune response in susceptible individuals, need to be validated. Further association studies can help to explain this complex picture and find new therapeutic targets. The aim of this review is to summarize current knowledge of genetics in motility disorders of the upper gastrointestinal tract, addressing how genetics contributes to the development of achalasia and functional dyspepsia respectively.

Is ineffective esophageal motility associated with gastropharyngeal reflux disease?

AIM： TO evaluate the association between IEM and gastropharyngeal reflux disease （GPRD） in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms. METHODS： A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms （e.g. globus, hoarseness, or cough） were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups. RESULTS;： A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups. CONCLUSION： There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.

Use of Clostridium botulinum toxin in gastrointestinal motility disorders in children

More than a century has elapsed since the identification of Clostridia neurotoxins as the cause of paralytic diseases. Clostridium botulinum is a heterogeneous group of Gram-positive, rod-shaped, spore-forming, obligate anaerobic bacteria that produce a potent neurotoxin. Eight different Clostridium botulinum neurotoxins have been described(A-H) and 5 of those cause disease in humans. These toxins cause paralysis by blocking the presynaptic release of acetylcholine at the neuromuscular junction. Advantage can be taken of this blockade to alleviate muscle spams due to excessive neural activity of central origin or to weaken a muscle for treatment purposes. In therapeutic applications, minute quantities of botulinum neurotoxin type A are injected directly into selected muscles. The Food and Drug Administration first approved botulinum toxin(BT) type A in 1989 for the treatment of strabismus and blepharospasm associated with dystonia in patients 12 years of age or older. Ever since, therapeutic applications of BT have expanded to other systems, including the gastrointestinal tract. Although only a single fatality has been reported to our knowledge with use of BT for gastroenterological conditions, there are significant complications ranging from minor pain, rash and allergic reactions to pneumothorax, bowel perforation and significant paralysis of tissues surrounding the injection(including vocal cord paralysis and dysphagia). This editorial describes the clinical experience and evidence for the use BT in gastrointestinal motility disorders in children.

Habitual rapid food intake and ineffective esophageal motility

AIM:To study non-cardiac chest pain(NCCP) in relation to ineffective esophageal motility(IEM) and rapid food intake.METHODS:NCCP patients with a self-reported habit of fast eating underwent esophageal manometry for the diagnosis of IEM.Telephone interviews identified eating habits of additional IEM patients.Comparison of manometric features was done among IEM patients with and without the habit of rapid food intake and healthy controls.A case study investigated the effect of 6-mo gum chewing on restoration of esophageal motility in an IEM patient.The Valsalva maneuver was performed in IEM patients and healthy controls to assess the compliance of the esophagus in response to abdominal pressureincrease.RESULTS:Although most patients diagnosed with NCCP do not exhibit IEM,remarkably,all 12 NCCP patients who were self-reporting fast eaters with a main complaint of chest pain(75.0%) had contraction amplitudes in the mid and distal esophagus that were significantly lower compared with healthy controls [(23.45 mmHg(95%CI:14.06-32.85)vs 58.80 mmHg(95%CI:42.56-75.04),P < 0.01 and 28.29 mmHg(95%CI:21.77-34.81) vs 50.75 mmHg(95%CI:38.44-63.05),P < 0.01,respectively)].In 7 normal-eating IEM patients with a main complaint of sensation of obstruction(42.9%),the mid amplitude was smaller than in the controls [30.09 mmHg(95%CI:19.48-40.70) vs 58.80 mmHg(95%CI:42.56-75.04),P < 0.05].There was no statistically significant difference in manometric features between the fast-eating and normal-eating groups.One NCCP patient who self-reported fast eating and was subsequently diagnosed with IEM did not improve with proton-pump inhibition but restored swallow-induced contractions upon 6-mo gum-chewing.The Valsalva maneuver caused a markedly reduced pressure rise in the mid and proximal esophagus in the IEM patients.CONCLUSION:Habitual rapid food intake may lead to IEM.A prospective study is needed to validate this hypothesis.Gum-chewing might strengthen weakened esophageal muscles.

Pediatric intestinal motility disorders

Pediatric intestinal motility disorders affect many children and thus not only impose a significant impact on pediatric health care in general but also on the quality of life of the affected patient.Furthermore,some of these conditions might also have implications for adulthood.Pediatric intestinal motility disorders frequently present as chronic constipation in toddler age children.Most of these conditions are functional,meaning that constipation does not have an organic etiology,but in 5% of the cases,an underlying,clearly organic disorder can be identified.Patients with organic causes for intestinal motility disorders usually present in early infancy or even right after birth.The most striking clinical feature of children with severe intestinal motility disorders is the delayed passage of meconium in the newborn period.This sign is highly indicative of the presence of Hirschsprung disease(HD),which is the most frequent congenital disorder of intestinal motility.HD is a rare but important congenital disease and the most significant entity of pediatric intestinal motility disorders.The etiology and pathogenesis of HD have been extensively studied over the last several decades.A defect in neural crest derived cell migration has been proven as an underlying cause of HD,leading to an aganglionic distal end of the gut.Numerous basic science and clinical research related studies have been conducted to better diagnose and treat HD.Resection of the aganglionic bowel remains the gold standard for treatment of HD.Most recent studies show,at least experimentally,the possibility of a stem cell based therapy for HD.This editorial also includes rare causes of pediatric intestinal motility disorders such as hypoganglionosis,dysganglionosis,chronic intestinal pseudo-obstruction and ganglioneuromatosis in multiple endocrine metaplasia.Underlying organic pathologies are rare in pediatric intestinal motility disorders but must be recognized as early as possible.

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.

Correlation of acid reflux and esophageal motility in patients with gastroesophageal reflux disease

Objective:To explore the relationship between acid reflux and esophageal motility in patients with gastroesophageal reflux disease.Methods:From January 2018 to December 2019,80 patients with typical gastroesophageal reflux symptoms such as reflux and heartburn were randomly selected from the Department of Gastroenterology,First Affiliated Hospital of guangxi university of chinese medicine.The patients were divided into pathological group,sensitive group and physiological group based on the percentage of acid exposure time and reflux-symptom correlation.The GerdQ score,quality of life score,esophageal acid test and esophageal manometry related parameters of the three groups of patients were compared.Results:Compared with the sensitive group and the physiological group,the GerdQ score,DeMeester score,orthostatic acid reflux time,orthostatic acid reflux time,longest acid reflux time and acid reflux times in the pathological group were significantly higher.Sf-36 score,lower esophageal sphincter pressure and effective rate of deglutition were all significantly reduced,with statistically significant differences(P<0.05).Compared with the physiological group,the GerdQ score of the sensitive group was higher.The sf-36 score was low,and the differences were statistically significant(P<0.05).The acid indexes in the sensitive group were higher than those in the physiological group,but the differences were not statistically significant(P>0.05).Compared with the physiological group,the distal contraction integral and the amplitude of the lower esophageal sphincter 3cm above the pathological group and the sensitive group decreased significantly(P<0.05).There were no statistically significant differences in the length of the lower esophageal sphincter,the length of the lower esophageal sphincter in the abdominal segment,the amplitude of the upper esophageal sphincter at 7cm and 11cm and the peristaltic wave velocity of the esophageal body in the three groups(P>0.05).Conclusion:the decrease of lower esophageal sphincter pressure is the key factor leading to pathological acid reflux,and acid reflux is closely related to distal contraction integral and peristaltic amplitude of 3cm on lower esophageal sphincter in patients with gastroesophageal reflux disease.

Huoxue Tongjiang decoction-resisted reflux esophagitis by activation stem cell factor/c-kit/interstitial cell of cajal pathway and regulating the T-helper 17/regulatory T-cells balance in rats

Background:Huoxue Tongjiang decoction(HXTJD)is an effective prescription for treating reflux esophagitis(RE).We investigated the effects of HXTJD on esophageal motility and mucosal inflammation in a rat RE model.Methods:Chemical composition of HXTJD was analyzed by ultrahigh-performance liquid chromatography Q-Orbitrap mass spectrometry(MS).The change rates of mean contraction tension forces,mean amplitudes,and mean frequencies for the lower esophageal sphincter(LES)were recorded using the isolated tissue bath system,mechanical tension transducer,and PowerLab physiological recorder.After weighing the stomach,the phenol red labeling method was used to measure the gastric emptying rate.The LES ultrastructure was observed through transmission electron microscopy.Immunofluorescence and western blotting were used to detect the number of interstitial cells of Cajal(ICC)and the expression levels of c-kit protein,connexin43(Cx43),and stem cell factor(SCF).Flow cytometric analysis and enzyme-linked immunosorbent assay were conducted to detect the percentages of T helper 17(Th17)cells and regulatory T(Treg)cells and the serum concentrations of interleukin 6(IL-6),interleukin 17(IL-17),and interleukin 10(IL-10)in the rats.Results:We identified 28 chemical constituents in HXTJD.Regarding esophageal motility,we revealed that HXTJD increased the mean contraction tension forces,mean amplitudes,and mean frequency change rate of LES and the gastric emptying rate;decreased stomach weight;and improved the LES ultrastructure.Additionally,HXTJD increased the number of ICC-positive cells,and c-kit,Cx43,and SCF expression levels.Regarding esophageal inflammation,HXTJD significantly decreased the percentage of Th17 cells,and IL-6 and IL-17 concentrations,and increased the percentage of Treg cells and IL-10 concentration.Conclusion:HXTJD was found to be efficacious in the rat RE model.It may promote esophageal motility and alleviate the inflammatory response by activating the SCF/c-kit/ICC pathway and regulating the Th17/Treg cell balance.

Suprasellar cistern tuberculoma presenting as unilateral ocular motility disorder and ptosis:A case report

BACKGROUND Intracranial tuberculoma is a rare and serious type of tuberculosis,which mostly occurs in the frontoparietal and cerebellar hemispheres,with predominance in the gray-white matter junction area,while tuberculomas only in the cistern are extremely rare with only a few reported cases in the literature.We describe a unique case of isolated tuberculoma in the suprasellar cistern,with only right ocular motility disorder and upper eyelid ptosis.CASE SUMMARY A 5-year-old boy without any medical history presented with right ocular motility disorder and upper eyelid ptosis one month ago.He had no history of fever,headache,vomiting,convulsions,or limb weakness.Neurological examination showed right third cranial nerve palsy with restrictions of eye movements and ptosis,pupil dilation and negative light reflex.Imaging suggested a spaceoccupying lesion in the suprasellar cistern with calcification and ring-enhancement.Moreover,no Mycobacterium tuberculosis was found in cerebrospinal fluid by polymerase chain reaction(PCR).The lesion was initially diagnosed as a tumor,while postoperative pathology combined with PCR indicated tuberculoma.The patient continued postoperative anti-tuberculosis treatment.At present,the patient's condition is stable and the symptoms are partially relieved compared with those before surgery.CONCLUSION This case confirmed that isolated intracranial tuberculoma can occur in the suprasellar cistern.Therefore,for space-occupying lesions in the suprasellar cistern,tuberculoma should be included in the differential diagnosis even if there is no history or indication of tuberculosis infection.

Electroacupuncture at ST25 inhibits jejunal motility:Role ofsympathetic pathways and TRPV1

AIM: To investigate whether electroacupuncture(EA) at ST25 affects jejunal motility in vivo and if so, whether a sympathetic pathway is involved.METHODS: Jejunal motility was assessed using a manometric balloon placed in the jejunum approximately about 3-5 cm away from the suspensory ligament of the duodenum in anesthetized animals. The effects of EA at ST25 were measured in male Sprague-Dawley rats, some of which were treated with propranolol or clenbuterol(EA intensities: 1, 3, 5, 7, and 9 m A), and in male transient receptor potential vanilloid-1(TRPV1)(capsaicin receptor) knockout mice(EA intensities: 1, 2, and 4 m A).RESULTS: Anesthetized rats exhibited three types of fasting jejunal motor patterns(types A, B, and C), and only type C rats responded to EA stimulation. In type C rats, EA at ST25 significantly suppressed the motor activity of the jejunum in an intensity-dependent manner. The inhibitory effect of EA was weakened by propranolol(β adrenoceptor antagonist) and disappeared with clenbuterol(β adrenoceptor agonist) induced inhibition of motility, suggesting that the effect of EA on motility is mediated via a sympathetic pathway. Compared with wild-type mice, EA at ST25 was less effective in TRPV1 knockout mice, suggesting that this multi-modal sensor channel participates in the mechanism. CONCLUSION: EA at ST25 was found to inhibit jejunal motility in an intensity-dependent manner, via a mechanism in which sympathetic nerves and TRPV1 receptors play an important role.

Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia

AIM: To investigate the relationship between upper esophageal sphincter abnormalities achalasia treatment METHODS: We performed a retrospective study of 41 consecutive patients referred for high resolution esophageal manometry with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of Upper esophageal sphincter(UES) abnormality, and clinical and manometric profiles were compared.Correlation between UES abnormality and sub-type(i.e.,hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness,psychiatric illness, surgical history, dominant presentingsymptom, treatment type, age and gender were also evaluated.RESULTS: Among all 41 patients, 24(58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profiles. Among those with UES abnormalities, the majority were either hypertensive(41.67%) or had impaired relaxation(37.5%) as compared to hypotensive(20.83%), although this did not reach statistical significance(P = 0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority(78.57%) had good treatment response, as compared to 21.43% with poor treatment response(P = 0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality(P = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality(P = 0.017).CONCLUSION: The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function.

Endoscopic management for congenital esophageal stenosis: A systematic review

Congenital esophageal stenosis(CES) is an extremely rare malformation, and standard treatment have not been completely established. By years of clinical research, evidence has been accumulated. We conducted systematic review to assess outcomes of the treatment for CES, especially the role of endoscopic modalities. A total of 144 literatures were screened and reviewed. CES was categorized in fibromuscularthickening, tracheobronchial remnants(TBR) and membranous web, and the frequency was 54%, 30% and 16%, respectively. Therapeutic option includes surgery and dilatation, and surgery tends to be reserved for ineffective dilatation. An essential point is that dilatation for TBR type of CES has low success rate and high rate of perforation. TBR can be distinguished by using endoscopic ultrasonography(EUS). Overall success rate of dilatation for CES with or without case selection by using EUS was 90% and 29%, respectively. Overall rate of perforation with or without case selection was 7% and 24%, respectively. By case selection using EUS, high success rate with low rate of perforation could be achieved. In conclusion, endoscopic dilatation has been established as a primary therapy for CES except TBR type. Repetitive dilatation with gradual step-up might be one of safe ways to minimize the risk of perforation.