Esophageal Motor Disorders Research Articles

Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia

BackgroundPrimary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative ‘oesophagus-preserving’ procedure in patients with end-stage achalasia.MethodsWe present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires.ResultsFour patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux.ConclusionTo our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a ‘rescue’ procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Oesophageal motor disorders and oesophageal endoscopic involvement in patients with systemic sclerosis: a systematic association?

Introduction Although oesophageal motor disorders (OMDs) are frequent in systemic sclerosis (SSc), the frequency of associated endoscopic lesions is unknown. We aimed at assessing the presence of endoscopic lesions in SSc patients with OMD. The secondary objective was to identify the clinical and serological profile of such patients. Methods This retrospective study included SSc patients suffering from OMD diagnosed by oesophageal high-resolution manometry (OHRM) and with recent upper gastro-intestinal endoscopy (UGIE). Clinical data collected were age, gender, body mass index, SSc disease duration, tobacco, SSc cutaneous type, non-digestive SSc visceral disorders, oesophageal symptoms, serological profile (autoantibodies), proton pump inhibitor use, time between SSc diagnosis and UGIE. Results 53 selected patients from 210 SSc patients investigated by OHRM in our department were included. Among these patients, 25 (47.2%) had endoscopic lesions: 18 (34.6%) had oesophagitis and 7 (13.5%) had Barrett’s oesophagus. The only two parameters significantly associated with endoscopic lesions were a shorter disease duration (6 vs. 11 years; p = .002) and a shorter delay between SSc diagnosis and UGIE (3 vs. 8.5 years; p = .002). No other clinical or biological parameters could help identify the patients at risk of endoscopic lesion. Conclusion In our study, only a shorter disease duration and a shorter delay between SSc diagnosis and UGIE were significantly associated with the presence of endoscopic lesions in patients with OMD, but no other parameters were identified. This study highlights the need to perform UGIE in SSc patients with OMD whatever their clinical symptoms.

Histopathological Analysis of Esophageal Mucosa in Patients with Achalasia.

Background/AimsAchalasia is an esophageal motor disorder that leads to functional esophageal obstruction. Food stasis and bacterial fermentation can predispose an individual to esophageal mucosal inflammation, causing multifocal dysplasia and increasing the risk of developing esophageal squamous cell carcinoma. We aimed to evaluate esophageal mucosal alterations in achalasia patients and determine clinical factors associated with the histopathological findings.MethodsFrom 2009 to 2013, we obtained endoscopic biopsies from the lower and middle esophagus of 22 patients with achalasia and 17 controls. Patients’ clinical data and histological severity of esophagitis were retrospectively analyzed. Additionally, immunohistochemical staining for CD3, CD20, Ki-67, and p53 was conducted.ResultsThe median age of achalasia patients was 49.5 years (range, 27 to 82 years), and there were nine males (40.9%). The median symptom duration was 5.8 years (range, 1 to 33.5 years), and 10 patients (45%) underwent previous treatment (nine, balloon dilation; one, botulinum toxin injection). Achalasia patients had significantly more severe esophagitis than did controls (p=0.001, lower esophagus; p=0.008, middle esophagus), and the number of CD3-positive lymphocytes exceeded that of CD20-positive lymphocytes (p<0.001). Achalasia patients also had a higher esophageal Ki-67 proliferation index (p=0.048). Although statistically nonsignificant, p53 expression was only observed in achalasia patients. There was no association between the histological severity of esophagitis and other clinicopathological findings.ConclusionsAchalasia patients showed significantly severe histological esophagitis and a high Ki-67 proliferation index, indicating an increased risk of neoplastic progression. Therefore, careful endoscopic inspection is necessary for the early detection of superficial neoplasia in these patients. (Gut Liver 2021;15-722)

Megaesófago como complicación de acalasia: Reporte de caso y revisión narrativa de la literatura

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.

Esophageal hypercontractility is abolished by cholinergic blockade.

Esophageal hypercontractility (EHC) is considered a major esophageal motor disorder of unclear etiology. Different mechanisms have been proposed, including an imbalance in inhibitory and excitatory esophageal innervation. We hypothesized that patients with EHC suffer from cholinergic hyperactivity. To interrogate the excitatory and inhibitory neurotransmission in EHC by assessing the esophageal motor response to atropine (ATR) and cholecystokinin (CCK), respectively, in EHC patients. We retrospectively reviewed patients who underwent high-resolution manometry (HRM) with pharmacologic challenge in a tertiary referral center between 2007 and 2017. We identified 49 EHC patients who were categorized based on frequency of hypercontractile peristaltic sequence into "frequent" and "infrequent" and motility diagnosis groups. Deglutitive pressure metrics and esophageal motor responses to ATR (12mcg/kg iv) and CCK (40ng/kg iv) were analyzed across groups. Atropine abolished hypercontractility across all groups studied, converting nearly half of patients to a motor pattern of ineffective esophageal motility. Abnormal CCK responses primarily occurred in the patient groups with concomitant outflow obstruction. Hypercontractility is cholinergically mediated in all esophageal motor disorders. Most patients with isolated EHC appear to have excessive cholinergic drive, rather than loss of inhibitory innervation, and might be candidates for treatment with anticholinergic agents.

Diagnostic Approach for Esophagogastric Junction Outflow Obstruction.

Esophageal manometry is the gold standard test for diagnosing primary esophageal motility disorder. With the various metrics of the high-resolution esophageal manometry, the Chicago classification provides a standard approach for the manometric diagnosis of esophageal motor disorders. In the Chicago classification, the esophagogastric junction dysfunction is an important major motor disorder, which includes achalasia subtypes and esophagogastric junction outflow obstruction. Esophagogastric junction outflow obstruction is defined manometrically as normal or weak esophageal peristalsis with incomplete relaxation of the lower esophageal sphincter. It is a heterogeneous disorder and usually has a benign clinical course. The small portion of an esophagogastric junction outflow obstruction is early or variant achalasia. In such cases, treatments directing the lower esophageal sphincter, such as balloon dilatation or per oral endoscopic myotomy, may be necessary. An adjunctive high-resolution manometry provocation test or other esophageal function tests, such as timed barium esophagogram, can help select those patients and predict the treatment outcomes.

Comparison of High-Resolution Manometry in Patients Complaining of Dysphagia among Patients with or without Diabetes Mellitus

Introduction: Dysphagia is a common symptom that occurs in patients with diabetes mellitus (DM). There have been few prospective observational studies on esophageal motility disorders in DM using high-resolution manometry (HRM). This study aimed to clarify the characteristics of esophageal motility disorders using HRM in patients with dysphagia and compare them between DM and non-DM patients. Methods: Patients with dysphagia were prospectively recruited between October 2018 and July 2019. Patients (n = 89) underwent esophagogastroduodenoscopy and HRM and completed the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Manometry parameters and motility disorder classifications were compared between DM and non-DM patients. We also investigated the differences in clinical backgrounds and questionnaire scores among DM patients with normal and abnormal manometry results. Results: A higher prevalence of esophageal motility disorder was observed in DM patients (60%, 21/35) compared to non-DM patients (29.6%, 16/54) (p = 0.001). The prevalence of minor disorders such as ineffective esophageal motor disorder and fragmented peristalsis was significantly higher (45 vs. 11%), and the distal contractile integral, integrated relaxation pressure, and contractile front velocity values were lower in the DM group. Among DM patients, those with abnormal esophageal motility had a significantly higher prevalence of neuropathy, retinopathy, and nephropathy, as well as higher reflux or constipation scores on the GSRS, than those with normal results. Conclusions: Among patients with dysphagia, the frequency of minor esophageal motility disorders was higher in DM patients than in non-DM patients. Abnormal esophageal motility related to poor esophageal clearance was associated with higher prevalence of diabetic complications.

Clinical characteristics and esophageal motility in Sjögren's syndrome: A single‐center study in Taiwan

AbstractSjögren's syndrome is an autoimmune disease that may cause inflammation of exocrine glands, including the salivary glands. Some patients with Sjögren's syndrome also have gastrointestinal disease, such as gastroesophageal reflux disease. A few studies have shown that an association might exist between Sjögren's syndrome and esophageal motility disorder, but the results have been inconsistent. This study aimed to investigate the relationships between clinical symptoms and esophageal motility function in patients with Sjögren's syndrome. Fifty‐six patients with suspected esophageal reflux or motility disease who had undergone esophagogastroduodenoscopy and esophageal manometry were retrospectively enrolled. Thirteen patients were diagnosed as having Sjögren's syndrome according to the American‐European Consensus Criteria. Forty‐three patients without any rheumatic disease or esophageal motor disorder were designated as the control group. We compared the clinical symptoms and endoscopic and esophageal manometric findings between the Sjögren's syndrome and the control groups. Acid regurgitation was more prevalent in the Sjögren's syndrome group (53.8%) than in the control group (11.6%) (P = .003), but the endoscopic findings of reflux esophagitis were similar in both groups (Sjögren's: 38.5%; control: 39.5%; P = .945). Barrett's esophagus was more prevalent in the Sjögren's syndrome group than in the control group (15.4% vs 0%, respectively; P = .051). The upper esophageal sphincter was shorter in the Sjögren's syndrome group than in the control group (2.38 ± 0.65 cm vs 3.07 ± 0.74 cm, respectively; P = .003). More reflux symptoms and distinct motility patterns were found in the Sjögren's syndrome group as compared with the control subjects.

Flip Technology for Assessing Esophageal Structural and Motor Disorders: a Skeptic's View.

Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy. FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results-Results from a multicenter French cohort.

Jackhammer esophagus (JE) is a hypercontractile esophageal motor disorder defined by at least two swallows with a distal contractile integral (DCI) >8000mmHg.s.cm during high-resolution manometry (HRM). The relationship between symptoms and hypercontractility and the response to therapies have been poorly evaluated. The aim of this study was to determine the clinical presentation, manometric diagnosis, and therapeutic results in a large cohort of JE patients. Patients with JE diagnosed among the HRM tests performed in nine academic French centers from 01/01/2010 to 08/31/2016 were included. Patient charts were reviewed to collect clinical and therapeutic data. Among the 16264 HRM tests performed during this period, 227 patients (60.8±13.8years, 151 male) had JE (1.7%). Dysphagia was the most frequent symptom (74.6%), followed by regurgitation (37.1%) and chest pain (36.6%); 4.7% of the patients were asymptomatic. The diagnostic workup was heterogeneous, and only a minority of patients had esophageal biopsies. None of the individual symptoms were significantly associated with any of the manometric parameters defined, except for dysphagia, which was significantly associated with the mean of all DCIs >8000mmHg.s.cm (P=.04). Additionally, the number of symptoms was not associated with any manometric parameter. Medical treatment and endoscopic treatments had poor efficacy and a high relapse rate. Jackhammer esophagus is a rare motility disorder. Diagnostic workup is heterogeneous and should be standardized. Symptoms are poorly associated with manometric parameters. The medical treatments and endoscopic therapies currently used are inefficient.

Sa1315 EFFECTIVENESS AND SAFETY OF PER ORAL ENDOSCOPIC MYOTOMY IN ACALASIA COMPARING ANTERIOR AND POSTERIOR APPROACH IN A REFERENCE CENTER

Achalasia is an esophageal primary motor disorder, characterized manometrically by the incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. Heller's myotomy is the gold standard therapie, but per oral endoscopic myotomy (POEM), with similar clinical and manometric success, is considered a safe alternative, the submucosal wall approach possible anterior or posterior esophagus depending on operator experience. As gastroesophageal reflux disease (GERD) is its main complication, there is few evidence about wich approach is safer and more effective. To describe in patients with achalasia who undergo POEM the manometric characteristics, pre and post procedure clinics with 6-month follow-up and compare the effectiveness and complications in anterior and posterior approach. We include patients with a diagnosis of achalasia virgins to treatment, candidates for POEM with anterior or posterior approach at the Hospital 1ero de Octubre ISSSTE in Mexico City from 2016 to 2018. We exclude patients with previous endoscopic and surgical treatment and other esophageal motor disorders. At the 6-month follow-up, we evaluated clinical response (Eckardt <3), manometric (integral relaxation pressure IRP <15 mmHg), endoscopy esophagitis (Los Angeles Classification), questionnaire of symptoms of gastroesophageal reflux (GERD Q> 8 points) and 24-hour pH-metry (Demeester> 14.7). Descriptive statistics were used; For difference of proportions between the 2 techniques in non-parametric variables X2and for parametric variables t of student; The statistical package SPSS V.22 was used and a p value of less than 0.05 was considered statistically significant. 51 patients were included, 21 with type II achalasia (41.2%); Average age of 59.3 years (25-88 years), 32 women (62.7%). Baseline Eckardt score of 9, baseline IRP of 35.7 mm Hg. Anterior approach in 29 cases (56.9%). The average procedure time was 62.3 minutes (range 34-118), the anterior technique with 60.3 minutes (p=0.348). In the follow-up clinical and manometric response of 90.2% in both groups, without significant differences between them. The most frequent adverse event was subcutaneous emphysema in 11 cases (21.6%), with a greater tendency in posterior approach 31.8% (p=0.114); In 4 patients perforations without difference between approaches (p=0.417) resolved with endoscopic management. Esophagitis was diagnosed in 15 cases (29.4%), positive pH-metry by Demeester in 33.3% of cases without significant differences. POEM is a safe procedure in both approaches (anterior or posterior), with no differences in procedure time and adverse events. We obtained a clinical and manometric success in the similar follow-up between groups, without finding significant differences in the presence of GERD by clinic, endoscopy and 24-hour pH-metry.

Peroral endoscopic myotomy (POEM) for dysphagia and esophageal motor disorder after antireflux fundoplication.

Laparoscopic fundoplication is the treatment of severe and refractory gastroesophageal reflux disease (GERD). It induces dysphagia in 5 % - 10 % owing to a tight valve ± esophageal motility disorders (EMD), with challenging management. We assessed the first case series assessing peroral endoscopic myotomy (POEM) in such a situation. A retrospective case series including eight patients with severe dysphagia after laparoscopic fundoplication who were treated by POEM. They were assessed clinically by Eckardt and Mellow - Pinkas dysphagia scores, and by high resolution manometry (HRM). The procedure was a regular esophageal POEM, mainly posterior, including a myotomy of the wrap. The objectives were to evaluate the clinical efficacy, technical difficulties, and complications of this approach. HRM showed aperistalsis in 6 /8 patients and raised lower esophageal sphincter (LES) pressure in 5 /8. The median preoperative Eckardt and dysphagia scores were 5 and 3.5, respectively. The procedure was completed in 7 /8 patients, with a clinical efficacy rate (normalization of both scores) of 75 % (6 /8). Although the submucosa seemed more fibrotic and vascularized, no severe complications occurred. POEM is a newly described therapeutic option to consider for managing dysphagia due to EMD after laparoscopic fundoplication.

Durability of Esophageal Motor Disorders Identified on High-Resolution Esophageal Manometry: A Case Series.

Background/AimDiagnosis of esophageal motor disorders using high-resolution esophageal manometry (HREM) may result in medical, endoscopic or surgical intervention. However, prior to any intervention, durability of the HREM findings should be established. The aim of this case series was to assess 25 patients who had undergone HREM twice, at least 6 months apart, and to determine the durability of the initial manometric diagnosis.Methods and PatientsThis is a case series of 25 patients who underwent HREM at least twice, 6 months apart, at a large safety net hospital. All patients were evaluated in between the tests for any clinical intervention. Demographics, patients’ indication for HREM and clinical presentation were documented as well.ResultsOf the 25 patients, HREM results improved in 32%, worsened in 20% and were unchanged in 48%. Some interventions were employed between the first and second HREM diagnosis. Those associated with an improved diagnosis included doubling the proton pump inhibitor (PPI) dose, re-starting a PPI, adding a histamine 2 blocker (H2 blocker) and use of empiric dilation.ConclusionsIn this case series, about half of the patients undergoing two esophageal manometries, at least 6 months apart, demonstrated lack of durability of their initially diagnosed esophageal motor disorder.

Retrospective study on symptoms and treatment modalities used and short-term follow up of achalasia cardia in Indian setting.

BackgroundAchalasia cardia is a rare esophageal motor disorder that is frequently diagnosed late.AimThe aim of this study was to study the symptoms, treatment given, and response to treatment in patients with achalasia cardia in an Indian setting.Materials and methodsThis retrospective study included all patients diagnosed with achalasia cardia on high‐resolution esophageal manometry, using Chicago Classification v 3.0. On follow up, patients were contacted by telephone, and details of the treatment given and response were recorded in a predesigned pro forma. We excluded overseas patients, postoperative cases of achalasia, and those in whom the manometry catheter could not be passed across the gastroesophageal junction.ResultsA total of 452 patients (260 males, median age 44.5 years) were included in the study cohort. The major symptoms included dysphagia for solids and liquids (428, 94.7%), regurgitation (360, 79.6%), naso‐oral regurgitation (182, 40.3%), weight loss (322, 71.3%), and chest pain (158, 35%). Type 2 achalasia (229, 50.6%) was the most common subtype, followed by type 3 (154, 34.1%). Chest pain was more common in type 3, and weight loss and naso‐oral regurgitation were more common in type 2 achalasia. A majority of patients underwent Heller's myotomy and pneumatic dilatation. Of 280 patients for whom treatment details were available, 98% reported good response to endoscopic/surgical management.ConclusionThe predominant symptoms of achalasia cardia vary per the manometric subtype. Heller's myotomy and pneumatic dilatation are the most commonly used treatment options. Response to treatment is good. The choice of treatment modality was likely influenced by financial reasons and availability of local expertise.

Normal Functional Luminal Imaging Probe Panometry Findings Associate With Lack of Major Esophageal Motility Disorder on High-Resolution Manometry

A normal esophageal response to distension on functional luminal imaging probe (FLIP) panometry during endoscopy might indicate normal esophageal motor function. We aimed to investigate the correlation of normal FLIP panometry findings with esophageal high-resolution manometry (HRM) and outcomes of discrepant patients. We performed a retrospective study using data from a registry of patients who completed FLIP during sedated endoscopy. We identified 111 patients with normal FLIP panometry findings (mean age, 42 y; 69% female) and corresponding HRM data. A normal FLIP panometry was defined as an esophagogastric junction (EGJ) distensibility index greater than 3.0 mm2/mm Hg, an absence of repetitive retrograde contractions, and a repetitive antegrade contraction pattern that met the Rule-of-6s: ≥6 consecutive antegrade contractions of ≥6-cm in length, at a rate of 6 ± 3 contractions per minute. HRM findings were classified by the Chicago classification system version 3.0. HRM results were classified as normal motility in 78 patients (70%), ineffective esophageal motility in 10 patients (9%), EGJ outflow obstruction in 20 patients (18%), and 3 patients (3%) as other. In patients with EGJ outflow obstruction based on HRM, the integrated relaxation pressure normalized on adjunctive swallows in 16 of 20 patients (80%), and in 8 of 9 patients (88%) who completed a barium esophagram and had normal barium clearance. Thus, although 23 of 111 patients (21%) with normal FLIP panometry had abnormal HRM findings, these HRMs often were considered to be false-positive or equivocal results. All patients with an abnormal result from HRM were treated conservatively. In a retrospective cohort study, we found that patients with normal FLIP panometry results did not have a clinical impression of a major esophageal motor disorder. Normal FLIP panometry results can exclude esophageal motility disorders at the time of endoscopy, possibly negating the need for HRM in select patients.

IDIOPATHIC ACHALASIA PRIMARILY DIAGNOSED AS BULIMIA NERVOSA: THE IMPORTANCE OF THE NUTROLOGYST

Idiopathic achalasia is a primary esophageal motor disorder characterized byesophageal aperistalsis and abnormal lower esophageal sphincter relaxation in responseto deglutition. Bulimia nervosa is an eating disorder, which amongst other symptomspresents with self-induced vomiting after repetitive episodes of binge eating in order toprevent weight gain. The present study reports the case of a female patient initiallydiagnosed with bulimia nervosa, after ruling out an etiology of organic cause throughlab tests and endoscopy. The patient was referred to a nutrologyst for treating the eatingdisorder, and after nutritional evaluation, she received nutritional supplementation dueto severe dysphagia, regurgitation and weight loss. As diagnostic criteria of bulimianervosa were not met, a further investigation was conducted, which eventuallyconfirmed idiopathic achalasia through two specific tests: digitalesophagogastroduodenal seriography, and esophageal manometry. Chagas disease, themajor cause of idiopathic achalasia in Brazil, was ruled out by specific lab test. In viewof the severity of the disease, the patient underwent urgent cardiomyotomy andfundoplication. Later, balloon dilators were also used in two occasions. After sixteenmonths of medical and nutrology follow-up, the patient now is in good nutritional statusand was able to go back to her daily activities and healthy lifestyle.

Triosephosphate isomerase, carbonic anhydrase, and creatinine kinase-brain isoform are possible antigen targets in patients with achalasia.

Idiopathic achalasia is an uncommon esophageal motor disorder. The disease involves interaction between inflammatory and autoimmune responses. However, the antigens related to the disease are still unknown. To identify the possible antigen targets in muscle biopsies from lower esophageal sphincter (LES) of achalasia patients. Esophageal biopsies of patients with type I and type II achalasia and esophagogastric junction outflow obstruction (EGJOO) were analyzed. Lower esophageal sphincter muscle biopsy from a Healthy organ Donor (HD) was included as control for two-dimensional gel electrophoresis. Immunoblotting of muscle from LES lysate with sera of type I, type II achalasia, or type III achalasia, sera of EGJOO and sera of healthy subjects (HS) was performed. The target proteins of the serum were identified by mass spectrometry Matrix-assited laser desorption/ionization time-of-flight (MALDI-TOF). The proteomic map of muscle from LES tissue lysates of type I, and type II achalasia, EGJOO, and HD were analyzed and divided into three important regions. We found a difference in the concentration of certain spots. Further, we observed the serum reactivity of type I achalasia and type II achalasia against 45 and 25kDa bands of type I achalasia tissue. Serum of type III achalasia and EGJOO mainly recognized 25kDa band. Bands correspond to triosephosphate isomerase (TPI) (25kDa), carbonic anhydrase (CA) (25kDa) and creatinine kinase-brain (CKB) isoform (45kDa). We identify three antigen targets, TPI, CA, and CKB isoform, which are recognized by sera from patients with achalasia.

Efficacy of per-oral endoscopic myotomy for the treatment of non-achalasia esophageal motor disorders

Per-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD). Patients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6months. Ninety patients (mean age 66years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I-II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I-II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I-II achalasia and type III achalasia, respectively (p = 0.03). Although less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD.

Esophageal motility disorders in children with dysphagia: the utility of the Chicago classification.

esophageal manometry is the standard criterion for the evaluation of dysphagia and the diagnosis of a primary motor disorder of the esophagus in adults and children. to describe the diagnosis according to the Chicago classification (CC) v3.0 in children with dysphagia, in whom an esophageal motility disorder was documented. The associated comorbidities were also determined. an observational retrospective study was performed of 54 patients evaluated for dysphagia, who had undergone a high-resolution manometry (HREM). a normal HREM was found in 52 % (n = 28) of the children, whereas 48 % (n = 26) had some esophageal motility disorder. The most frequent diagnosis was ineffective esophageal motility and achalasia. Excluding previously healthy children, most children had a history of autoimmune disease and intellectual disability. an esophageal motor disorder can be diagnosed in nearly half of infants and children with dysphagia. In this study, all esophageal diseases could be classified according to the CC v3.0. HREM should be considered for the evaluation of children with dysphagia, in addition to other studies.

Esophageal motility disorders in systemic sclerosis

Systemic sclerosis is an autoimmune disease characterized by vasculopathy and tissue fibrosis. Esophageal disorders are often associated. The diagnosis is confirmed and characterized by high-resolution esophageal manometry (HRM). This study aims to describe the esophageal motility disorders found by high-resolution esophageal manometry, in patients followed for systemic sclerosis. An observational study carried out between April 2018 and January 2020, including 23 patients with systemic sclerosis according to EULAR/ACR 2013 criteria, referred for high-resolution esophageal manometry. We used the Chicago V3.0 classification to order esophageal motor disorders into two categories: major and minor disorders of peristalsis. Four parameters were analyzed: lower esophageal sphincter resting pressure (LES), distal latency (DL) and distal contractile integral (DCI) and integrated relaxation pressure (IRP). IRP was normal in all cases. The digestive symptoms were: gastroesophageal reflux in 10 cases (43.4%) and dysphagia in 6 cases (26.2%). Seven patients were asymptomatic (30.4%). HRM revealed a major disorder of esophageal peristalsis in 14 cases (60.9%), minor disorders in 4 patients (17.4%) and was normal in 5 cases (21.7%). There was; hypotonia of the lower esophageal sphincter (LES) with absent contractility in 8 cases (44.5%), only absence of contractility in 6 cases (33.3%), hypotonia of the lower esophageal sphincter (LES) with ineffective motility in 4 cases (22.2%). High-resolution esophageal manometry should be considered in all patients with systemic sclerosis even in the absence of digestive symptoms. In our series, motility disorders were present in 78.3% of cases.