Esophageal Muscle Research Articles

Human cardiomyocytes are more susceptible to irreversible electroporation by pulsed electric field than human esophageal cells.

Pulse electric field‐based (PEF) ablation is a technique whereby short high‐intensity electric fields inducing irreversible electroporation (IRE) are applied to various tissues. Here, we implemented a standardized in vitro model to compare the effects of biphasic symmetrical pulses (100 pulses, 1–10 μs phase duration (d), 10–1000 Hz pulse repetition rate (f)) using two different human cellular models: human‐induced pluripotent stem cell‐derived cardiomyocytes (hiPSC‐CMs) and human esophageal smooth muscle cells (hESMCs) cultured in monolayer format. We report the PEF‐induced irreversibly electroporated cell monolayer areas and the corresponding electric field thresholds (EFTs) for both cardiac and esophageal cultures. Our results suggest marked cell type specificity with EFT estimated to be 2–2.5 times lower in hiPSC‐CMs than in hESMCs when subjected to identical PEF treatments (e.g., 0.90 vs 1.85 kV/cm for the treatment of 100 pulses with d = 5 μs, f = 10 Hz, and 0.65 vs 1.67 kV/cm for the treatment of 100 pulses with d = 10 μs, f = 10 Hz). PEF treatment can result in increased temperature around the stimulating electrodes and lead to unanticipated thermal tissue damage that is proportional to the peak temperature rise and to the duration of the PEF‐induced elevated temperatures. In our study, temperature increases ranged from less than 1°C to as high as 30°C, however, all temperature changes were transient and quickly returned to baseline and the highest observed ∆T returned to 50% of its maximum recorded temperature in tens of seconds.

Molecular Survey on Sarcocystis Species in Slaughtered Sheep in Hamedan, Iran

Introduction: Sarcocystis is an apicomplexan heteroxenous protozoan leading to adverse consequences for production in sheep with remarkable importance in public health. The current study aimed to investigate molecular prevalence data on Sarcocystis spp. in slaughtered sheep using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in Hamedan, Iran.
 Methods and materials: The carcass of 60 sheep slaughtered in the Hamedan abattoir were sampled from May 2019 to June 2020. Heart, scapular, esophageal and diaphragmatic muscles were macroscopically examined and recorded as positive in case of the presence of tissue cyst. In this regard, 50 grams of each muscle was sliced and transferred to the laboratory on ice for microscopic and molecular analysis. The molecular identification of Sarcocystis spp. was performed using the PCR-RFLP method.
 Results: By microscopy, all specimens contained bradyzoites in cysts. The molecular analysis further revealed Sarcocystis species, including Sarcocystis gigantea (S. gigantea), S. tenella, and S. arieticanis.
 Conclusion: The present study emphasized that three Sarcocystis spp. were circulating among sheep and carnivorous hosts in the investigated area. Further molecular investigations are highly recommended to better evaluate the epidemiology of this zoonotic parasite.

595. LAPAROSCOPIC HELLER’S MYOTOMY WITHOUT FUNDOPLICATION. CURRENT EVIDENCE

Abstract Achalasia is a rare esophageal motility disorder which affects the esophageal smooth muscle layer, causing absent or spastic peristalsis, and absent or partial lower esophageal sphincter (LES) relaxation with an increased LES tone. Laparoscopic Heller’s myotomy is the gold standard surgical therapy of esophageal achalasia. The role of fundoplication to minimize GERD after myotomy is debatable. We studied our experience with Laparoscopic Heller Myotomy Without Fundoplication (LHM) for the treatment of esophageal achalasia. A retrospective analysis of prospectively collected data regarding consecutive patients that underwent LHM without fundoplication for the treatment of esophageal achalasia was conducted. All patients were operated between September 1st 2018 and January 1st 2022. Patients included in this study were adults (>18 years old) without upper age limit. All participants completed a subjective dysphagia score questionnaire, received an Eckardt Score preoperatively, as well as at 6 and 12 months following the myotomy procedure. Patients that were treated with endoscopic dilation POEM or esophagectomy were excluded from the study. Twenty-five patients underwent LHM myotomy without fundoplication during the study period. Median age was 42 years (Range: 25-90 years). Median operative time was 70 min (Range: 60-80 min). There was no conversion. Median length of stay was 2 days (Range: 1-15 days). There was one (n=1) mucosal perforation, in a 28-year-old male patient due to overeating, 4 days post LHM. He was treated with laparoscopic primary suturing. There was n=1 (4%) pathologic GERD noted post-operatively. The Eckardt score decreased from 6.5 ± 1.7 to 0.9 ± 1.4 at 1 month and to a 0.8 ± 1.1 at 12 months. Therapy of esophageal achalasia focuses on decreasing the outflow resistance of the GEJ caused by the dysfunctional LES. LHM is considered as the gold-standard therapy for most achalasia patients. LHM is considered safe and effective, while it has been associated with excellent results regarding the relief of dysphagia. There is a reportedly low incidence of new gastroesophageal reflux symptoms. There is no need for fundoplication following LHM since the incidence of GERD is relatively low.

Comparison of the nutritional composition of raw, boiled, roasted Macadamia (F. Muell. Macadamieae) and its application as an elder-friendly food

The purpose of this study is to establish an optimal pretreatment method that can improve the nutritional quality of Macadamia, and to develop viscous beverage products for the elderly with dysphagia to help prevent suffocation and improve nutritional imbalance. As a result, roasting Macadamia had a significant effect on increasing the unsaturated fatty acid and mineral content (p < 0.01) rather than raw and boiled. Next, a thickening agent was added to develop viscous nut breeze using roasted Macadamia for the elderly, who could easily choke even if they drank water due to weakened esophageal muscles. Therefore, it was confirmed that all thickening agents used in this study can be applied as elder-friendly foods suitable for Korean Industrial Standards, and the regression equation for viscosity change according to thickening agent concentration was ‘Y = 62,136X + 29.821 (R2 = 0.9676)' for xanthan gum, ‘Y = 59,271X – 200.79 (R2 = 0.9542)’ for locust bean gum, ‘Y = 4,069X – 7.4643 (R2 = 0.9578)’ for carrageenan, and ‘Y = 900X + 3.6429 (R2 = 0.9589)’ for gum arabic. In conclusion, this study can help prevent suffocation and improve nutritional imbalance by developing viscous nut breeze beverage products using roasted Macadamia for the elderly with dysphagia, and can be used as basic data for the elder-friendly food industry in the future. Meanwhile, as in this study, studies should be continuously conducted to reduce the nutritional imbalance of the elderly by changing the intake methods of various nuts.

Histopathological diagnosis for Sarcocystis spp. in slaughtered sheep and goats in Misan governorate/Iraq

This study aimed to determine and identify Sarcocystis spp. infection in sheep and goats in Misan governorate, Iraq. samples from oesophagus, diaphragm, tongue, and heart muscles were examined histologically for microscopic and macroscopic cyst , 70 out of 90 sheep 77.78 % had microscopic thick walled sarcocysts with mean 53 ×24.72 μm diagnosed as Sarcocystis tenella while 25 out of them 27.78 % had microscopic thin-walled sarcocysts with mean 49.45×33 μm diagnosed Sarcocystis arieticanis , esophagus showed the highest infection rate above all organs examined for thick – walled Sarcocystis while diaphragm was the highest for thin –walled Sarcocystis , the heart was the lowest infected organ for both type as 27.78% and 3.33% respectively . In goats 50 sample examined revealed 20 infected with thick walled sarcocysts only with different in distribution according to organs being high in esophagus 40% and lowest in heart 16% with mean measurement 60.61 × 37.75 μm diagnosed as Sarcocystis capracanis.

Does Achalasia Subtype III Need to be Treated Differently Than Type I and II? Pro Argument

Type III achalasia, previously known as spastic achalasia, has been a rare but challenging diagnosis to treat. While it is included in the same diagnostic and treatment paradigm of types I and II achalasia, conventional therapies such as Botulinum Toxin A injection, pneumatic dilation, and Heller myotomy have yielded poor outcomes. Given the longer segment of spastic esophageal muscle, per oral endoscopic myotomy (POEM) is emerging as the dominant treatment paradigm. As such, it behooves us to treat type III achalasia as the unique entity that it is rather than the “garden variety” achalasia.

Profile of major pork associated zoonotic parasites from northern India: A detailed seminal study

The present study was undertaken to document the status of three major pork associated zoonotic parasites, viz.Taenia solium cysticercus, Sarcocystis suihominis and Trichinella spp., in two north Indian states (Uttar Pradesh andUttarakhand). Masseter, diaphragm, tongue and oesophageal muscles were collected from 450 pigs (domestic: 445,wild: 05) and examined during November 2014 to October 2017. Muscle tissue samples were initially screened byvisual inspection followed by the muscle compression technique for visualization of the parasites. Tissue sampleswere also subjected to acid-pepsin digestion for the recovery of Trichinella spp. larvae. Out of the 450 pigs examined, T. solium cysticercus was detected in 41 (9.11%) samples, whereas sarcocysts were detected in 315 (70%) samples. Nurse cell bearing Trichinella spp. larvae were recorded in the muscle tissues of a single (0.22%) wild boar and none of the muscle tissue samples from domestic pigs were positive for Trichinella spp. infection. However, the exact species of Trichinella infecting wild boar could not be established morphologically. The findings of the study are of substantial importance for understanding the maintenance and distribution of zoonotic parasites transmitted through pork consumption in the country.

Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group.

Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p=0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p=0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p=0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p=0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p=0.03). We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.

Molecular Identification of Sarcocystis Species in Sheep from Lithuania.

Simple SummaryMembers of the genus Sarcocystis (Apicomplexa: Sarcocystidae) are protozoans that have a two-host, prey–predator life cycle. These parasites are most thoroughly examined in economically important animals. Several Sarcocystis species are known to form macroscopic and microscopic sarcocysts in the muscle tissues of sheep. A previous study carried out in Lithuania has shown a maximum Sarcocystis infection prevalence in sheep and a high parasite burden; however, species were not identified. In the present study, diaphragm, oesophagus, and heart samples of 69 sheep raised in Lithuania were examined. No macrocysts were detected in the sheep muscles, while the microcysts found corresponded to two morphological types. By molecular methods, two Sarcocystis species, S. arieticanis and S. tenella, using canids as their definitive hosts, were identified for the first time in sheep from Lithuania. Both species were detected in all the studied animals. In summary, very high detection rates of S. arieticanis and S. tenella ranging from 82.61% to 100% were established in the examined diaphragm, oesophagus, and heart muscle samples of sheep.Data on the distribution of different Sarcocystis species in various muscles of sheep are scarce. In the present study, 190 diaphragm, oesophagus, and heart muscle samples of 69 sheep raised in Lithuania were examined for the presence of Sarcocystis spp. Under a light microscope, two morphological types of microcysts corresponding to S. arieticanis and S. tenella were detected. Eight and 12 sarcocysts of S. arieticanis and S. tenella, respectively, were isolated and characterised by the sequencing of a portion of cox1. The sequence comparisons revealed the highest similarity between European and Asian isolates of S. arieticanis and S. tenella obtained from domestic sheep and other wild Caprinae hosts. Based on peptic digestion, nested PCR targeting cox1, and sequencing, a 100% infection prevalence of S. arieticanis and S. tenella was observed in the 69 studied animals. The occurrence of S. tenella was significantly higher in the diaphragm than in the oesophagus (χ2 = 13.14, p < 0.001), whereas differences in the prevalence of S. arieticanis in the studied muscle types were insignificant (χ2 = 1.28, p > 0.05). Further molecularly based epidemiological studies are needed to compare the prevalence of Sarcocystis species in various muscles of sheep raised in different geographic regions.

Determination of Region-Specific Roles of the M3 Muscarinic Acetylcholine Receptor in Gastrointestinal Motility.

The specific role of the M3 muscarinic acetylcholine receptor in gastrointestinal motility under physiological conditions is unclear, due to a lack of subtype-selective compounds. The objective of this study was to determine the region-specific role of the M3 receptor in gastrointestinal motility. We developed a novel positive allosteric modulator (PAM) for the M3 receptor, PAM-369. The effects of PAM-369 on the carbachol-induced contractile response of porcine esophageal smooth muscle and mouse colonic smooth muscle (ex vivo) and on the transit in mouse small intestine and rat colon (in vivo) were examined. PAM-369 selectively potentiated the M3 receptor under the stimulation of its orthosteric ligands without agonistic or antagonistic activity. Half-maximal effective concentrations of PAM activity for human, mouse, and rat M3 receptors were 0.253, 0.345, and 0.127μM, respectively. PAM-369 enhanced carbachol-induced contraction in porcine esophageal smooth muscle and mouse colonic smooth muscle without causing any contractile responses by itself. The oral administration of 30mg/kg PAM-369 increased the small intestinal transit in both normal motility and loperamide-induced intestinal dysmotility mice but had no effects on the colonic transit, although the M3 receptor mRNA expression is higher in the colon than in the small intestine. This study provided the first direct evidence that the M3 receptor has different region-specific roles in the motility function between the small intestine and colon in physiological and pathophysiological contexts. Selective PAMs designed for targeted subtypes of muscarinic receptors are useful for elucidating the subtype-specific function.

Process Modelling, Scale-Up and Characterization of Acetaminophen Spray Dried Milk Powder as Novel Pediatric Dosage Form.

Successful drug therapy in children is contingent upon hassle-free administration of pediatric dosage forms. Pediatric patients suffer from difficulty in swallowing due to weak esophagus muscles in their early age. Considering this challenge liquid formulations are preferred over solid dosage form among pediatric patients to avoid the possibility of choking which can be a serious life-threatening condition in children. The main aim of the present research work was to develop a reconstitutable amorphous acetaminophen spray-dried milk powder (ASDM) as novel pediatric formulation. ASDM was prepared by spray drying process and the spray drying process was optimized using Box-Behnken design to study the effect of spray drying process parameters at X1 [inlet temperature], X2 [aspiration rate] and X3 [feed rate] to Y1 [% yield], Y2 [angle of repose], Y3 [Hausner's Ratio] and Y4 [Carr's Index] as dependent variables of ASDM. In addition, each batch was characterized for particle size by polarized light microscopy and drug entrapment. Predicted parameters from optimized spray drying process model were successfully employed to manufacture a scale up cum validation batch of ASDM, which showed notably improved yield and desirable flow properties. The scale-up validation batch was further characterized using thermal analysis, diffraction studies, spectroscopic analysis, dispersion studies, stability APAP in dispersion formulation and formulation stability studies to confirm the physico-chemical stability of ASDM. Thus, ASDM for oral use can serve as a promising pediatric formulation and the developed prototype formulation can be further extended to future newly discovered drugs with similar characteristics.

ESOPHAGEAL MANOMETRY PROFILE IN PATIENTS OF UPPER GASTROINTESTINAL SYMPTOMS IN WESTERN INDIA: A RETROSPECTIVE COHORT STUDY

INTRODUCTION: High-resolution esophageal manometry (HREM) is a technique to determine the pressure pattern which is a function of esophageal musculature and integrity of LES. The indications for HREM evaluation include evaluation of nonobstructive dysphagia, symptoms of regurgitation and noncardiac or atypical chest pain unexplained by endoscopic evaluation To analyse profile of esophageal motility disorders in patient presenting with refractoryAIM: gastroesophageal reflux disease (GERD), dysphagia and atypical chest pain in tertiary care centre in Western India METHODS: We enrolled patient presented with refractory GERD, dysphagia and atypical chest pain from Jan 2020 to March 2022 at Department of gastroenterology, National Institute of Medical College &amp; R, Jaipur. Upper GI endoscopy and high-resolution esophageal manometry was done in all patients Ineffective esophageal peristalsis,RESULTS: achalasia cardia, hypercontractile esophagus, fragmented peristalsis and esophagogastric junction outflow obstruction were common diagnosis made by high resolution esophageal manometry In our study ineffectiveConclusion: esophageal motility most common and achalasia cardia second most common diagnosis identified on esophageal manometry

Genetic encoding of an esophageal motor circuit.

SUMMARYMotor control of the striated esophagus originates in the nucleus ambiguus (nAmb), a vagal motor nucleus that also contains upper airway motor neurons and parasympathetic preganglionic neurons for the heart and lungs. We disambiguate nAmb neurons based on their genome-wide expression profiles, efferent circuitry, and ability to control esophageal muscles. Our single-cell RNA sequencing analysis predicts three molecularly distinct nAmb neuron subtypes and annotates them by subtype-specific marker genes: Crhr2, Vipr2, and Adcyap1. Mapping the axon projections of the nAmb neuron subtypes reveals that Crhr2nAmb neurons innervate the esophagus, raising the possibility that they control esophageal muscle function. Accordingly, focal optogenetic stimulation of cholinergic Crhr2+ fibers in the esophagus results in contractions. Activating Crhr2nAmb neurons has no effect on heart rate, a key parasympathetic function of the nAmb, whereas activating all of the nAmb neurons robustly suppresses heart rate. Together, these results reveal a genetically defined circuit for motor control of the esophagus.

A case study: An ayurvedic management of Urdhwaga Amlapitta with special reference to hyperacidity

Vitiation of Agni in Amashaya (stomach) region due to various reasons causes Amlapitta. Some of the common Pitta vitiating factors are fasting, eating between meals, worry, hurry, spicy foods etc. These factors derange the Pachaka Pitta (digestive enzymes etc.) and as a result Pachaka pitta vitiates. Thus developed condition is called Amlapitta. Hydrochloric acid (HCl) when not utilized well, or when produced in large quantity in the stomach region causes inflammation of stomach (gastric = related to stomach), that is called gastritis. This can derange the digestive procedures. The increased or normal level of HCl can destroy the soft tissue (epithelium) lining of esophagus, stomach, duodenum etc. If not managed on time this can give rise to ulceration (breech in tissue).Usually the esophageal sphincter muscle contracts thus preventing the stomach acid from shooting up into the esophagus, but if this muscle are not functioning properly, the acid can slip past it and this is when heartburn symptoms start, which is called Gastroesophageal reflux. Due to lifestyle changes and changes in food habits people are mainly suffering from GIT disorders. Amlapitta among them is a most commonly seen disease. This article is a case study of a 40 years male patient with signs &amp; symptoms of Urdhwaga Amlapitta. Patient was treated with ayurvedic medicine and principles of Ayurveda according to Rogavastha and Doshavastha. This case study shows potential of ayurveda and it proves ayurveda has evidence based treatment. In this case study patient of Urdhwaga Amlapitta was treated with Shamana Aushadhi according to his Prakruti, Dosha, Dhatu and Mala. Rapid but steady improvement in patient’s complaints.

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

Why is endosonography insufficient for residual diagnosis after neoadjuvant therapy for esophageal cancer? Solutions using muscle layer evaluation.

BACKGROUNDThe diagnosis of residual tumors using endoscopic ultrasound (EUS) after neoadjuvant therapy for esophageal cancer is considered challenging. However, the reasons for this difficulty are not well understood.AIMTo investigate the ultrasound imaging features of residual tumors and identify the limitations and potential of EUS.METHODSThis exploratory prospective observational study enrolled 23 esophageal squamous cell carcinoma patients receiving esophagectomy after neoadjuvant therapy [15 patients after neoadjuvant chemotherapy (NAC) and 8 patients after chemoradiotherapy (CRT)] at the Department of Surgery, Chiba University Hospital, between May 2020 and October 2021. We diagnosed the T stage for specimens using ultrasound just after surgery and compared ultrasound images with the cut surface of the fixed specimens of the same level of residual tumor. The ratio of esophageal muscle layer defect measured by ultrasound was compared with clinicopathological factors. Furthermore, the rate of reduction for the muscle layer defect was evaluated using EUS images obtained before and after neoadjuvant therapy.RESULTSThe accuracy of T stage rate was 61% (n = 14/23), which worsened after CRT (38%, n = 3/8) than after NAC (73%, n = 11/15) because of overstaging. Moreover, pT0 could not be diagnosed in all cases. The detection rate of residual tumor for specimens using ultrasound retrospectively was 75% (n = 15/20). There was no correlation between after-NAC (79%, n = 11/14) and after-CRT (67%, n = 4/6) detection rate. The detection of superficial and submucosal types was poor. The pathologic tumor size and pathological response were correlated. Tumor borders were irregular and echogenicity was mixed type after CRT. There was a correlation between the pT stage (pT0/1 vs pT2/3) and the length of muscle layer circumference (P = 0.025), the length of muscle layer defect (P < 0.001), and the ratio of muscle layer defect (P < 0.001). There was also a correlation between the pT stage and the rate of muscle layer defect reduction measured by EUS (P = 0.001).CONCLUSIONCompared to pathological images, some tumors are undetectable by ultrasound. Focusing on the esophageal muscle layer might help diagnose the depth of the residual tumor.

Effect of esophageal muscle fibrosis on prognosis of per-oral endoscopic myotomy (POEM) in achalasia patients.

Although esophageal smooth muscle fibrosis of achalasia (AC) patients has been described, the role and mechanism remain unclear. The aim of this study was to evaluate the fibrosis in the distal esophageal muscle in patients with AC and explore its relationship with prognosis of per-oral endoscopic myotomy (POEM). Lower esophageal sphincter (LES) muscle from forty patients undergoing POEM for AC were obtained at the time of surgery. Control specimens consisted of similar muscle taken from distal esophagectomy for gastric tumors. The muscle fibrosis were assessed by Masson staining and confirmed by immunohistochemistry for collagen I and III. The total number of eosinophil within the myenteric propria were counted. In addition, clinical data were obtained through electronic medical records. Statistical comparison between groups were made. A significantly higher proportion of fibrosis in AC as compared with controls (P = 0.000). Eosinophil count, TGF-β1, collagen I, and III were higher than those of control (P = 0.000, P = 0.001, P = 0.011, and P = 0.002, respectively). TGF-β1, collagen I, and III were positively correlated with eosinophil count (all P &lt; 0.05). Furthermore, the proportion of severe LES fibrosis in patients who failed to respond to POEM two years after operation was higher than that in responders (P = 0.028). And, Eckardt score two years after POEM was also positively correlated with degree of fibrosis-related cytokines (all P &lt; 0.05). Smooth muscle fibrosis was prominent in lower part of esophagus of AC and positively correlated with severity of symptoms two years after POEM. The fibrosis might be relevant to eosinophil infiltration and TGF-β1. Further studies are required to more clearly delineate the mechanism of muscle fibrosis and its correlation with prognosis of therapy for this idiopathic disease.

Achalasia.

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

SPARC: The structure of vagal nociceptive nerve fibers in the mouse esophagus

The esophagus is innervated by nociceptive sensory afferent nerve fibers originating from the vagus nerve. The nature of the vagal nociceptive fiber innervation, specifically which esophageal layers, however, remains unknown. We hypothesized that the vagal nociceptive TRPV1+ afferent fibers innervate the esophageal mucosa. We evaluated our hypothesis by using genetic neuronal tracing in several mutant mice, including two new strains we generated. The wholemount preparations of separated esophageal mucosa and muscle were immunostained for appropriate fluorescent proteins and imaged by spinning‐disk confocal microscopy. In the TRPV1‐Flp/RC: FLTG mice(N=8) in which TRPV1‐expressing cells express tdTomato the TRPV1+ fibers with varicose appearance densely innervated both the mucosa and the muscle. In the mucosa the TRPV1+ fibers are located just beneath the epithelium, run in parallel registers of two or more fibers, have craniocaudal orientation and branch repeatedly. In the muscle the TRPV1+ fibers form a dense network in the myenteric plexus innervating virtually all myenteric ganglia forming intraganglionic varicose endings (IGVEs). Many TRPV1+ fibers connecting IGVEs run in parallel to the fibers of the outer and inner striated muscle. In the TRPV1‐Flp/Tac1‐Cre/RC:FLTG mice(N=4) in which GFP is selectively expressed in cells positive for both TRPV1 and Tac1 (the marker of esophageal nociceptors derived from neural crest) the esophageal innervation by TRPV1+/Tac1+ fibers mimicked the dense innervation by TRPV1+ fibers. In contrast, in the TRPV1‐Flp/P2X2‐Cre/RC:FLTG mice(N=4) in which GFP is selectively expressed in cells positive for both TRPV1 and P2X2 (the marker of esophageal nociceptors derived from placodes) the TRPV1+/P2X2+ fibers were almost absent in the esophagus. Consistent with this finding, in the P2X2‐Cre mice unilaterally injected with AAV9‐FLEX‐EGFP virus into vagal ganglia(N=2) in which GFP is selectively expressed in vagal P2X2+ fibers, the nodose TRPV1‐negative tension mechanosensor nerve terminals (intraganglionic laminar endings) were visualized in the esophageal muscle. Finally, in the TRPV1‐Cre mice unilaterally injected with AAV9‐FLEX‐EGFP virus into vagal ganglia(N=3), in which only the vagal TRPV1+ fibers express GFP, the vagal TRPV1+ fibers had the same pattern as TRPV1+/Tac1+ fibers, but with lower density and patchy distribution. Our data indicate that vagal nociceptive TRPV1+ fibers innervate both the esophageal mucosa and myenteric ganglia and originate from neural crest‐derived jugular portion of the vagal jugular‐nodose ganglia complex.

Autoantigen characterization in the lower esophageal sphincter muscle of patients with achalasia.

Serum anti-myenteric autoantibodies define autoimmune achalasia and tissue MMP-9 activity may locally process autoantigenic proteins in the muscle of the lower esophageal sphincter (LES) of achalasia patients. Biopsies of the LES muscle from 36 achalasia patients, 6 esophagogastric junction outflow obstruction (EGJOO) patients, and 16 transplant donors (TD) were compared in a blind cross-sectional study. Histological characteristics such as inflammation, fibrosis, presence of ganglion cells, cells of Cajal, GAD65, PNMA2, S-100, P substance, and MMP-9 proteoforms in tissue were assessed by H&E and Picrosirius Red staining and immunohistochemistry analysis. Anti-neuronal antibodies, onconeural antigens, recoverin, SOX-1, titin, zic4, GAD65, and Tr were evaluated by immunoblot/line assay. Tissue of achalasia patients had heterogeneous inflammatory infiltrates with fibrosis and contrasting higher levels of activated MMP-9, as compared with EGJOO and TD. Moreover, lower ganglion cell percentages and cell of Cajal percentages were determined in esophageal tissues of achalasia patients versus TD. The tissues of achalasia versus EGJOO patients had higher GAD65 and PNMA2 protein expression. Unexpectedly, these proteins were absent in TD tissue. S-100 and P substance had similar expression levels in tissues of achalasia patients versus TD and EGJOO. Most of the achalasia sera had anti-GAD65 (83%) and anti-PNMA2 (90%) autoantibodies versus EGJOO (17% and 33%, respectively) and healthy volunteers (10% and 0%, respectively). Tissue-specific ectopic expression of GAD65 and PNMA/Ta2 and active MMP-9, associated with the presence of specific autoantibodies directed against these proteins, might participate in the pathophysiology of achalasia triggering and/or perpetuating autoimmune disease.