Sphincter Relaxation Research Articles

Spontaneous Internal Anal Sphincter Relaxation During High-resolution Anorectal Manometry Is Associated With Peripheral Neuropathy and Higher Charlson Comorbidity Scores in Patients With Defecatory Disorders.

Background/AimsWe aimed to evaluate associations between comorbidities, peripheral neuropathy, and spontaneous internal anal sphincter relaxation (SAR) in patients with defecatory disorders.MethodsA patient was considered to exhibit SAR during high-resolution anorectal manometry (HR-ARM) when the nadir pressure is < 15 mmHg and the time from onset to relaxation was ≥ 15 seconds in the resting pressure frame. A case-control study was performed using HR-ARM data collected from 880 patients from January 2010 to May 2015. We identified 23 cases with SAR (median age 75 years; 15 females; 12 fecal incontinence and 11 constipation). We compared HR-ARM values, Charlson index comorbidity scores, neuropathy, and the prevalence of diseases that potentially cause neuropathy between controls and SAR patients. Each SAR case was compared to 3 controls. Controls were selected to match the age, gender, and examination year of each SAR case.ResultsCompared to controls (26.1%), SAR patients (52.2%) exhibited a significantly higher frequency of fecal incontinence. SAR patients also had higher Charlson index scores (5 vs 4, P = 0.028). Nine of 23 SAR patients (39.1%) exhibited peripheral neuropathy— this frequency was higher than that for the control group (11.6%; P = 0.003). Diseases that potentially cause neuropathy were observed in 17 of 23 SAR cases and 32 of 69 controls (P = 0.022).ConclusionsSAR develops in patients with constipation and fecal incontinence but is more common in patients with fecal incontinence. Our controlled observational study implies that SAR is associated with peripheral neuropathy and more severe comorbidities.

The Benefits of Nonablative Radiofrequency Treatment of the Lower Esophageal Sphincter After Transoral Incisionless Fundoplication

Non-ablative radiofrequency treatment to the lower esophageal sphincter (Stretta) has been shown to be beneficial after failed Nissen fundoplication. To our knowledge, this is the first report of Stretta after transoral incisionless fundoplication (TIF). This patient is a 17-year-old female who had gastroesophageal reflux disease (GERD) symptoms for 9 years. She presented with heartburn, regurgitation, and epigastric discomfort. She used omeprazole for 9 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm sliding hiatal hernia and DeMeester score of 25. The GERD Health-Related Quality of Life (GERD-HRQL) score on omeprazole was 14. Patient underwent a TIF procedure, which was uneventful. Her symptoms resolved, and she discontinued omeprazole. Six months later, she had episodes of repeated violent vomiting followed by recurrence of regurgitation, nausea, bloating, and dysphagia. She resumed omeprazole. Diagnostic workup included gastric emptying scan, which was normal. EGD showed no hiatal hernia and partial disruption of the TIF valve. DeMeester score was 36.3. Esophageal manometry with impedance showed intact peristalsis and normal relaxation of the lower esophageal sphincter. The patient underwent Stretta, which was uneventful. The previous TIF did not increase the complexity of the procedure. There were no immediate or postoperative complications. The patient reported gradual improvement of her symptoms with complete resolution 2 months postoperatively. She discontinued omeprazole. The GERD-HRQL score 17 months post-Stretta was 0. This case highlights the feasibility, safety, and efficacy of performing Stretta following TIF. It provides an endoluminal alternative to complex revisional antireflux surgery. Prospective studies with longer follow-up are required to validate this concept.

Homozygous mutation in murine retrovirus integration site 1 gene associated with a non-syndromic form of isolated familial achalasia.

Achalasia is a condition characterized by impaired function of esophageal motility and incomplete relaxation of the lower esophagus sphincter, causing dysphagia and regurgitation. Rare cases of early-onset achalasia appear often in combination with further symptoms in a syndromic form as an inherited disease. Whole genome sequencing was used to investigate the genetic basis of isolated achalasia in a family of Tunisian origin. We analyzed the function of the affected protein with immunofluorescence and affinity chromatography study. A homozygous nonsense mutation was detected in murine retrovirus integration site 1 (MRVI1) gene (Human Genome Organisation Gene Nomenclature Committee (HGNC) approved gene symbol: IRAG1) encoding the inositol 1,4,5-trisphosphate receptor 1 (IP3 R1)-associated cyclic guanosine monophosphate (cGMP) kinase substrate (IRAG). Sanger sequencing confirmed co-segregation of the mutation with the disease. Sequencing of the entire MRVI1 gene in 35 additional patients with a syndromic form of achalasia did not uncover further cases with MRVI1 mutations. Immunofluorescence analysis of transfected COS7 cells revealed GFP-IRAG with the truncating mutation p.Arg112* (transcript variant 1) or p.Arg121* (transcript variant 2) to be mislocalized in the cytoplasm and the nucleus. Co-transfection with cGMP-dependent protein kinase 1 isoform β (cGK1β) depicted a partial mislocalization of cGK1β due to mislocalized truncated IRAG. Isolation of protein complexes revealed that the truncation of this protein causes the loss of the interaction domain of IRAG with cGK1β. In individuals with an early onset of achalasia without further accompanying symptoms, MRVI1 mutations should be considered as the disease-causing defect.

Is esophageal manometry essential for the diagnosis of achalasia? Identifying patients with achalasia by the esophageal clearance method.

Achalasia is a disease characterized by inadequate relaxation of the lower esophageal sphincter (LES) and impaired peristalsis, for which esophageal motor function testing is essential in making a definitive diagnosis. However, the diffusion rate of esophageal pressure testing in Japan is low. We, therefore, examined whether achalasia could be identified by esophageal clearance testing with low-density barium (Timed Barium Esophagogram: TBE). 126 cases (62 males, median age of 46years), excluding those who had not undergone TBE during their initial laparoscopic Heller-Dor surgery, were chosen as the subjects from among those who were diagnosed with achalasia from November 2012 when HRM was introduced. The type of dilation, maximum esophageal transverse diameter, and esophageal clearance measurements by TBE were retrospectively examined. With respect to TBE, 200mL of 45 weight% low-density barium was ingested as quickly as possible, after which the barium column heights (H0, H1, H2, and H5) were measured 1min, 2min, and 5min following ingestion. The types of dilation indicated included: straight type (105 cases, 83%); sigmoid type (20 cases, 16%); and advanced sigmoid type (1 case, 1%). The maximum transverse diameter of the esophagus was 45 (34-54) mm, with Grade I (d < 30mm) in 33 cases, Grade II (35mm < d < 60mm) in 75 cases, and Grade III (d < 60mm) in 18 cases. The values for H0, H1, H2, and H5 were 162 (117-201) mm, 142 (98-199) mm, 130 (94-183) mm, and 119 (77-178) mm, respectively. 114 cases (90.5%) were not cleared after 5min, while 12 cases (9.5%) were cleared by 5min later (H1 = 0 + H2 = 0 + H5 = 0) and 7 cases (5.6%) by 2min later (H1 = 0 + H2 = 0), with only 6 cases (4.8%) having complete clearance within 1min (H1 = 0). Moreover, the degree of dilatation in patients with complete clearance within 1min was three patients (2.4%) each for Grade I and Grade II, respectively. Approximately 2.4% of achalasia cases had mostly normal esophageal clearance and no esophageal dilation. Based on the state of esophageal clearance by TBE and the maximum transverse diameter of the esophagus, it seems by and large possible to identify achalasia cases.

BOTULINUM TOXIN TYPE A AND LATERAL SUBCUTANEOUS SPHINCTEROTOMY FOR CHRONIC ANAL FISSURE WITH THE SPHINCTER SPASM. WHAT TO CHOOSE? (systematic literature review and meta-analysis)

INTRODUCTION: for the treatment of chronic anal fissure, various surgical techniques are used, the main difference between which is the method of eliminating the anal sphincter spasm. One of the most serious postoperative complications is the development of anal incontinence. To date, there are a number of methods for drug-induced relaxation of the internal sphincter, which can significantly reduce the risk of developing anal incontinence after surgery.AIM: to evaluate the safety and effectiveness of botulinum toxin type A (BTA) and lateral subcutaneous sphincterotomy (LSS) in the treatment of chronic anal fissure with sphincter spasm.METHODS: a systematic review and meta-analysis of 7 selected randomized clinical trials comparing the results of treatment of chronic anal fissure using BTA and LSS was performed. The results of treatment of 489 patients were analyzed with an assessment of the following indicators: the incidence of epithelization of fissures, postoperative complications, development of anal incontinence and the disease recurrence. RESULTS: In the BTA group, the incidence of fissure epithelization is 0.88 times lower than in the LSS group (OR=0.12; CI=0.06;0.22; p&lt;0.00001). There were no statistical differences in the rate of postoperative complications in both groups (OR=1.07; CI=0.50;2.30; p=0.85). The risk of developing postoperative anal incontinence is 0.86 times lower in the BTA group than in the LSS group (OR=0.14; CI=0.03;0.64; p=0.01). The risk of relapse after lateral subcutaneous sphincterotomy is 6.06 times lower than when using botulinum toxin type A (OR=6.06; CI=3.52;10.42; p&lt;0.00001).CONCLUSION The use of botulinum toxin type A in the treatment of chronic anal fissure reduces the risk of developing postoperative anal incontinence, but this method is significantly inferior to lateral subcutaneous sphincterotomy in terms of the rate of chronic anal fissure epithelization.

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.

Surgical management of achalasia.

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience‐based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

Laparoscopic Heller Myotomy and Toupet Fundoplication for Achalasia.

Achalasia manifests as failure of relaxation of the lower esophageal sphincter resulting in dysphagia. Although there are several medical and endoscopic treatment options, laparoscopic Heller myotomy has excellent short- and long-term outcomes. This article describes in detail our surgical approach to this operation. Key steps include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy (3 cm as opposed to the conventional 1-2 cm gastric myotomy), a minimum 6 cm esophageal myotomy through circular and longitudinal muscle layers, and a Toupet partial fundoplication. We routinely use intraoperative endoscopy both to check for inadvertent full-thickness injury and to assess completeness of the myotomy and the geometry of the anti-reflux wrap.

Short-term outcome after singular hydraulic EsoFLIP dilation in patients with achalasia: A feasibility study.

Achalasia is a chronic esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, determined by an elevated integrated relaxation pressure (IRP>15mmHg) and absent peristalsis. Goal of treatment is facilitation of flow across the EGJ but minimizing postinterventional reflux. A new advanced hydraulic dilation technology, the esophageal functional luminal imaging probe (EsoFLIP), allows dynamic monitoring of hollow organ dimensions while performing hydraulic dilation. The aim of our study was to evaluate the treatment response after single EsoFLIP dilation in achalasia patients. Dilation was performed under endoscopic control with the EsoFLIP device using a self-developed dilation algorithm. Symptom scores were assessed by the Eckardt score (ES) before and 1-4weeks after intervention. Esophageal emptying before and after intervention was recorded with timed barium esophagogram. We studied 28 consecutive untreated achalasia patients (8 female) with a median age of 43years (range 19-82years) undergoing their first dilation performed with the EsoFLIP, aiming at a maximum dilation diameter of 25mm. Total ES was significantly reduced from 7 at baseline to 2 postintervention (P<.001). The median height of the barium column after 5minutes was significantly reduced from 4.5cm at baseline to 1.7cm (P=.0087). No major complications occurred. We found good efficacy in both subjective and objective short-term treatment outcome after singular EsoFLIP dilation in treatment-naive achalasia patients. Our findings suggest that EsoFLIP is a promising dilation technology that should be further studied in a larger, controlled setting with longer follow-up.

Characteristics of a Subset of Achalasia With Normal Integrated Relaxation Pressure.

Background/AimsIntegrated relaxation pressure (IRP) is a critical diagnostic criterion to define achalasia. However, there are some cases with typical symptoms and signs of achalasia but with normal IRP. The aim of this study is to evaluate the clinical characteristics of patients with achalasia with normal IRP and outcomes after peroral endoscopic myotomy (POEM).MethodsPatients with achalasia were collected in whom POEM was performed from November 2014 to April 2018 at CHA Bundang Medical Center. Achalasia with normal IRP was defined by findings compatible to achalasia in Eckardt score, endoscopy with endoscopic ultrasound, high-resolution manometry, impedance planimetry (EndoFlip), and timed esophagogram.ResultsPOEM was performed in 89 patients with achalasia; among them, 24 (27%) patients were diagnosed with achalasia with normal IRP. Patients with achalasia with normal IRP were older, had longer duration of symptom, and had a more tortuous esophagus. In EndoFlip, the distensibility index and cross-sectional area were higher in patients with normal IRP. Therapeutic outcomes showed no statistically significant differences. On correlation analysis, IRP had negative correlations with age, disease duration, and distensibility index.ConclusionsPatients with achalasia of normal IRP value were older and had longer disease duration and higher distensibility index and cross-sectional area than patients with achalasia with abnormal relaxation of lower esophageal sphincter. Therapeutic outcomes were not different between the 2 groups.

2019 Seoul Consensus on Esophageal Achalasia Guidelines.

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the “2019 Seoul Consensus on Esophageal Achalasia Guidelines”) were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Laparoscopic Heller Myotomy and Dor Fundoplication: How I Do It?

Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. Available treatment modalities are not curative but rather intend to relieve patient' symptoms. A laparoscopic Heller myotomy with Dor fundoplication is associated with high clinical success rates and low incidence of postoperative reflux. A properly executed operation following critical surgical steps is key for the success of the operation.

Esophagogastric Junction Opening Parameters Are Consistently Abnormal in Untreated Achalasia

Achalasia is a disorder of impaired lower esophageal sphincter (LES) relaxation and failed peristalsis traditionally characterized by manometry.1 As impaired LES relaxation is a mechanism of reduced esophagogastric junction (EGJ) opening, abnormally reduced EGJ distensibility assessed with functional luminal imaging probe (FLIP) was reported among patients with untreated achalasia.2-5 Therefore, we aimed to describe the performance characteristics of EGJ opening parameters on FLIP panometry among a large cohort of treatment-naïve achalasia patients.

Enfermedad por reflujo gastroesofágico

Gastro-oesophageal reflux disease (GERD) is a complication of maintained pathological reflux, in which there is an imbalance between protective and aggressive factors, favouring the latter. It has been postulated that the primary mechanism responsible is the transient relaxation of the lower oesophageal sphincter (LOS), although the presence of a hiatal hernia or a hypopressive LOS might contribute to the disease. The main clinical manifestations are pyrosis and regurgitation, although numerous other symptoms can present, such as dysphagia, odynophagia and even extraoesophageal manifestations. The diagnosis of GERD can be established by clinical improvement after 2 months of medical treatment; occasionally, upper endoscopy and other complementary tests are needed to rule out other entities. The mainstay of medical treatment is proton pump inhibitors, although surgery is sometimes required.

SPARC: Wireless Fecobionics Device in dogs

ObjectiveWe developed a novel wireless device (Fecobionics) for mapping colonic and anorectal neuromuscular function. Fecobionics measures pressures, cross‐sectional areas and bending of the device and transmits data wireless to a receiver unit outside the body (figure 1). This study evaluated the safety of the device in dogs relative to the predicate THD SensyProbe device for biofeedback. Furthermore, physiological data were obtained with Fecobionics.MethodsTwelve male Mongrel dogs with 25kg body weight were assigned into two groups: Fecobionics group and predicate control group (N=6 of each). Fecobionics and the predicate device were transanally inserted into rectum. Further, each group was divided into two sub‐groups: The acute group in which the animals were euthanized immediately after the evacuation of the device, and the chronic group in which the animals were terminated after 2 weeks. The animals were monitored daily. Tissue from different colon segments and anorectum were collected after the dogs were euthanized. HE staining and immunofluorescence staining were performed.ResultsAll procedures were performed successfully without complications. All chronic animals showed normal food intake and behavior after the procedure. Wireless transmission of Fecobionics data were without significant data loss or data error. Fecobionics studies demonstrated defecation pressures in the range 60–100cmH2O. The bending of the device, representative of the anorectal angle, was less than 30 degrees. The shape of the bag was obtained from the serial cross‐sectional area measurements. The shape of Fecobionics was cylindrical in rectum and changed to hourglass shape when it passed through the anal canal. No signs of inflammation were identified in the tissue sections examined histologically or immunohistochemically (macrophages and caspase‐3) in both Fecobionics and control groups.ConclusionsWireless Fecobionics is as safe as the predicate device, without inducing macro‐ or microscopic changes or inflammatory status of anorectal muscle. Novel physiological data were obtained. Dogs seems not to have an anorectal angle like humans, which makes defecatory efficacy more dependent on intrarectal pressure and anal sphincter relaxation compared to humans.Support or Funding InformationFundingNIH SPARC OT2OD025308The Fecobionics device (left), the wireless receiver (middle) and the data collection device (right).Figure 1

Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry.

Distal esophageal spasm (DES) is a rare major motility disorder in the Chicago classification of esophageal motility disorders (CC). DES is diagnosed by finding of ≥ 20% premature contractions, with normal lower esophageal sphincter (LES) relaxation on high-resolution manometry (HRM) in the latest version of CCv3.0. This feature differentiates it from achalasia type 3, which has an elevated LES relaxation pressure. Like other spastic esophageal disorders, DES has been linked to conditions such as gastroesophageal reflux disease, psychiatric conditions, and narcotic use. In addition to HRM, ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions. Functional lumen imaging probe (FLIP), a new cutting-edge diagnostic tool, is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP. Medical treatment in DES mostly targets symptomatic relief and often fails. Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time. Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.

Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD

A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. At a median follow-up of 14months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

Relationship Between Tongue Pressure and Pharyngeal Function Assessed Using High-Resolution Manometry in Older Dysphagia Patients with Sarcopenia: A Pilot Study.

Tongue pressure is often used to evaluate swallowing muscle strength in dysphagia patients with sarcopenia. However, the amount of tongue pressure that reflects pharyngeal swallowing function is unclear. The aims of this descriptive study were (1) to assess the association between tongue pressure and swallowing function using high-resolution manometry (HRM), (2) to evaluate whether manometric parameters were related to maximum tongue pressure (MTP) and other sarcopenia-related factors, and (3) to evaluate the manometric characteristics of pharyngeal swallowing in sarcopenic dysphagia. Sixteen patients with dysphagia (13 men; mean age 85.0 ± 6.6) who were diagnosed with sarcopenia and sixteen healthy subjects (10 men; mean age 33.6 ± 7.2) were included. Evaluation of HRM parameters including velopharyngeal contractile integral (VPCI), mesohypopharyngeal contractile integral (MHPCI), upper esophageal sphincter (UES) relaxation duration, and UES nadir pressure was performed. HRM parameters of patients were compared with MTP, sarcopenia factors, and manometric parameters of healthy subjects. The VPCI showed no statistically significant differences between patient and healthy groups. In the patient group, the MHPCI was significantly lower (126.1 ± 76.6 vs 193.2 ± 34.1mmHgcms; p = 0.003), UES nadir pressure was significantly higher (10.5 ± 27.5 vs -11.2 ± 6.7mmHg; p < 0.001), and UES relaxation duration (318.0 ± 152.4 vs 520.6 ± 60.0ms; p = 0.007) was significantly shorter than those in the healthy group. HRM parameters were not significantly correlated with MTP and sarcopenia factors. Older dysphagia patients with sarcopenia had weaker pharyngeal contractility and UES dysfunction. Manometric evaluation of pharyngeal function may not be significantly associated with MTP and sarcopenia-related factors. Further study is needed to clinically apply tongue pressure for evaluating sarcopenic dysphagia.

Síndrome PFAPA: reporte de un caso clínico

&#x0D; &#x0D; &#x0D; &#x0D; El síndrome PFAPA es la entidad más frecuente dentro de los síndromes de fiebres periódicas que pueden manifestarse desde la infancia. Es un síndrome autoinflamatorio caracterizado por una disfunción en las citoquinas, de carácter autolimitado y de etiología desconocida, aunque se han reportado casos de presentación familiar; lo que sugiere la existencia de una base genética de la enfermedad. Se presenta con episodios febriles que suelen acompañarse de aftas orales, adenopatías cervicales, faringoamigdalitis y síntomas constitucionales. En los exámenes de laboratorio es frecuente encontrar elevación marcada de la proteína C reactiva, leucocitosis y aumento de IgG, IgA e IgM. El diagnóstico se realiza utilizando los criterios modificados de Thomas, que incluyen parámetros clínicos, antecedentes y diagnósticos de exclusión. Se presenta el caso de un paciente de 4 años de edad que consultó a un hospital por un cuadro febril, movimientos tónico-clónicos generalizados, desviación de la mirada, sialorrea y relajación de esfínteres. También presentó cefalea de localización frontal y odinofagia. En la cavidad oral se observaron lesiones tipo aftas, y se evidenciaron adenopatías cervicales. El paciente no respondió al manejo con antibióticos, y se observó que cumplía con los criterios de diagnóstico para síndrome PFAPA, luego de descartarse un proceso infeccioso. Se inició terapia con corticoides con respuesta favorable y se concluyó que el paciente tenía un cuadro compatible con síndrome PFAPA.&#x0D; &#x0D; &#x0D; &#x0D;

Advances in research of traditional Chinese medicine for promoting bile secretion and excretion

Cholagogic traditional Chinese medicines refer to those that can promote bile secretion and excretion, strengthen gallbladder contraction and promote gallbladder emptying. They are mainly used to treat cholecystitis, gallstones, cholestasis, biliary tract infection, jaundice hepatitis and other diseases in clinical application. As a traditional medicine in our country, Chinese herbal medicines have many advantages, such as extensive resources, low cost, little or no toxic and side effects, and in addition, it is not easy for animals to produce drug resistance. With the progress of science and technology and the rapid development of traditional Chinese medicine, many achievements have been made in the research of cholagogic traditional Chinese medicines. Traditional Chinese medicine plays a cholagogic role mainly by promoting bile secretion, regulating SCP2 mRNA, FXR, BSEP and efflux transporter protein, dissolving cholesterol, promoting the relaxation of Oddi's sphincter and changing the composition of bile, etc. Traditional Chinese medicine decoction, traditional Chinese medicine preparation, Chinese medicine combined with acupuncture, ear acupoint pressing, soaking bath, western medicine and alike are often used to treat biliary system diseases in clinical practice. The effective rate of combination of traditional Chinese medicine and other methods was significantly higher than that of compound prescription, western medicine, acupuncture and soaking bath alone. General attack therapy and new therapies are also used in clinical treatment. The clinical effect of traditional Chinese medicine is remarkable. By means of literature review, the pharmacological effects, mechanism and clinical application of Chinese herbal medicines and compound prescriptions with gallbladder-promoting effect in the past 15 years were summarized in this paper. At the same time, some existing problems were found and prospects were expected.