Tertiary Contractions Research Articles

A202 A CASE OF MYCOBACTERIUM WOLINSKYI PULMONARY INFECTION SECONDARY TO LONG-STANDING ACHALASIA IN AN IMMUNOCOMPETENT PATIENT

Abstract Background Achalasia is an esophageal motility disorder resulting in chronic esophageal obstruction and stasis. Rapidly growing mycobacterium (RGM) pulmonary infections have been previously observed in individuals with underlying gastro-esophageal motility disorders. To date, pulmonary Mycobacterium wolinskyi infection (MWI) in the setting of achalasia has not previously been reported. Aims Our aim is to present a novel case of M. wolinskyi pneumonia in a patient with achalasia. We also searched the medical literature to identify previously reported associations between achalasia, chronic regurgitation symptoms and MWI. M. wolinskyi is an emerging clinical concern among RGMs. While primarily associated with post-operative, prosthetic joint and skin and soft tissue infections, M. wolinskyi pulmonary infections have not been documented to date in an immunocompetent patient. Methods We present a retrospective clinical case description of our case. We carried out a literature review from 1999 to Oct 2023, with the keywords "M. wolinskyi and infection. Results A 34-year-old male presented with a several-month history of productive cough, exertional dyspnea, fatigue, and unintentional weight loss of 17 kg over the past 6 months. Despite multiple courses of oral and intravenous antibiotics, there was no clinical improvement. His medical history included long-standing achalasia requiring previous pneumatic dilations. On admission, his chest X-ray revealed bilateral interstitial and alveolar infiltrates with consolidation. Routine microbiology and viral panels were negative. CT scan showed widespread bilateral consolidation and a dilated and fluid-filled esophagus. A timed barium swallow demonstrated dilated esophagus with irregular tertiary contractions and limited GE-J opening. Sputum cultures were positive for MWI on day 8 of admission (BACTEC MGIT). This was confirmed with lung biopsy demonstrating MWI with necrotizing granulomatous inflammation. The patient was prescribed a 12-month course of doxycycline, trimethoprim-sulfamethoxazole, and ciprofloxacin. Inpatient pneumatic dilation to 35 mm was performed. At discharge, his swallowing was subjectively improved, and a follow-up swallowing study noted improvement with no evidence of regurgitation. Conclusions Chronic esophageal obstruction provides an ideal lipid-rich environment for RGM infections. Related mycobacterial species have been isolated in pulmonary infections have been linked to chronic esophageal obstruction. To date, no cases of M. wolinskyi pulmonary infection with achalasia have been reported. We present a unique case of M. wolinskyi pulmonary infection in an immunocompetent patient with chronic achalasia, adding to our understanding of this emerging clinical concern. Funding Agencies None

Esophageal anatomy and physiology vary across spastic and non-spastic phenotypes of disorders of esophagogastric junction outflow.

Pathophysiologic mechanisms of disorders of esophagogastric junction (EGJ) outflow are poorly understood. We aimed to compare anatomic and physiologic characteristics among patients with disorders of EGJ outflow and normal motility. We retrospectively evaluated adult patients with achalasia types 1, 2, 3, EGJ outflow obstruction (EGJOO) or normal motility on high-resolution manometry who underwent endoscopic ultrasound (EUS) from January 2019 to August 2022. Thickened circular muscle was defined as ≥1.6 mm. Characteristics from barium esophagram (BE) and functional lumen imaging probe (FLIP) were additionally assessed. Of 71 patients (mean age 56.2 years; 49% male), there were 8 (11%) normal motility, 58 (82%) had achalasia (5 (7%) type 1, 32 (45%) classic type 2, 21 (30%) type 3 [including 12 type 2 with FEPs]), and 7 (7%) had EGJOO. A significantly greater proportion of type 3 achalasia had thickened distal circular muscle (76.2%) versus normal motility (0%; p < 0.001) or type 2 achalasia (25%; p < 0.001). Type 1 achalasia had significantly wider mean maximum esophageal diameter on BE (57.8 mm) compared to type 2 achalasia (32.8 mm), type 3 achalasia (23.4 mm), EGJOO (15.9 mm), and normal motility (13.5 mm). 100% type 3 achalasia versus 0% type 1 achalasia/normal motility had tertiary contractions on BE. Mean EGJ distensibility index on FLIP was lower for type 3 achalasia (1.2 mmHg/mm2 ) and EGJOO (1.2 mmHg/mm2 ) versus type 2 (2.3 mmHg/mm2 ) and type 1 achalasia (2.9 mmHg/mm2 ). Our findings suggest distinct pathologic pathways may exist: type 3 achalasia and EGJOO may represent a spastic outflow phenotype consisting of a thickened, spastic circular muscle, which is distinct from type 1 and 2 achalasia consisting of a thin caliber circular muscle layer with more prominent esophageal dilation.

Diagnostic methods to measure spastic segment and guide tailored myotomy length in type 3 achalasia.

Myotomy length in type 3 achalasia is generally tailored based on segment of spasticity on high-resolution manometry (HRM). Potential of length of tertiary contractions on barium esophagram (BE) or length of thickened circular muscle on endoscopic ultrasound (EUS) to guide tailored myotomy is less understood. This study aimed to assess agreement between spastic segments lengths on HRM, BE, and EUS among patients with type 3 achalasia. This retrospective study included adults with type 3 achalasia on HRM between November 2019 and August 2022 who underwent evaluation with EUS and/or BE. Spastic segments were defined as HRM-distance between proximal borders of lower esophageal sphincter and high-pressure area (isobaric contour ≥70 mmHg); EUS-length of thickened circular muscle (≥1.2 mm) from proximal border of esophagogastric junction (EGJ) to the transition to a non-thickened circular muscle; BE-distance between EGJ to proximal border of tertiary contractions. Pairwise comparisons assessed for correlation (Pearson's) and intraclass correlation classification (ICC) agreement. Twenty-six patients were included: mean age 66.9 years (SD 13.8), 15 (57.7%) male. Spastic segments were positively correlated on HRM and BE with good agreement (ICC 0.751, [95% CI 0.51, 0.88]). Spastic segments were negatively correlated with poor agreement on HRM and EUS (ICC -0.04, [-0.45, 0.39]) as well as BE and EUS (ICC -0.03, [-0.47, 0.42]). Length of spastic segment was positively correlated on HRM and BE while negatively correlated when compared to EUS, supporting the common use of HRM and highlighting the uncertain role for EUS in tailoring myotomy length for type 3 achalasia.

Atypical presentations and pitfalls of achalasia.

Achalasia is a rare disease with significant diagnostic delay and association with false diagnoses and unnecessary interventions. It remains unclear, whether atypical presentations, misinterpreted symptoms or inconclusive diagnostics are the cause. The aim of this study was the characterization of typical and atypical features of achalasia and their impact on delays, misinterpretations or false diagnoses. A retrospective analysis of prospective database over a period of 30years was performed. Data about symptoms, delays and false diagnoses were obtained and correlated with manometric, endoscopic and radiologic findings. Totally, 300 patients with achalasia were included. Typical symptoms (dysphagia, regurgitation, weight loss and retrosternal pain) were present in 98.7%, 88%, 58.4% and 52.4%. The mean diagnostic delay was 4.7years. Atypical symptoms were found in 61.7% and led to a delay of 6months. Atypical gastrointestinal symptoms were common (43%), mostly 'heartburn' (16.3%), 'vomiting' (15.3%) or belching (7.7%). A single false diagnosis occurred in 26%, multiple in 16%. Major gastrointestinal misdiagnoses were GERD in 16.7% and eosinophilic esophagitis in 4%. Other false diagnosis affected ENT-, psychiatric, neurologic, cardiologic or thyroid diseases. Pitfalls were the description of 'heartburn' or 'nausea'. Tertiary contractions at barium swallows, hiatal hernias and 'reflux-like' changes at endoscopy or eosinophils in the biopsies were misleading. Atypical symptoms are common in achalasia, but they are not the sole source for diagnostic delays. Misleading descriptions of typical symptoms or misinterpretation of diagnostic studies contribute to false diagnoses and delays.

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.

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

S414 A Retrospective Review: Are We Under-Utilizing Barium Swallow Studies After a Normal EGD in Patients with Dysphagia?

Introduction: Upper endoscopy (EGD) is an effective tool in the initial evaluation of patients >40 years old presenting with dysphagia and concomitant heartburn, odynophagia, and weight loss. However, it can miss subtle esophageal strictures, motility disorders, and extrinsic abnormalities which may be diagnosed with barium swallow study, or esophagram. In this study, we assessed the utility of barium swallow exam in patients presenting with dysphagia who had a grossly normal EGD. Methods: A retrospective analysis was conducted at a tertiary hospital from January 2018 through March 2019. Patients presenting with dysphagia who underwent both an EGD and barium swallow study with a 13mm pill (either before or after EGD) were included. Patients with an abnormal EGD were excluded. We analyzed esophagram results in patients who had a grossly normal EGD, and data was examined with univariate analysis. Results: 67 total patients underwent both an EGD and barium swallow study, of which 27 had a grossly normal EGD. The mean age (SD) of our study population (N=27) was 56.1 years (15.5), with 16 males. Of the 27 patients, 9 (33.3%) had a normal barium swallow exam while 18 (66.7%) patients had an abnormal exam. 7 patients had findings consistent with oropharyngeal dysphagia, 7 revealed structural issues manifested by difficulty of passage of a 13mm pill suggesting gastroesophageal junction obstruction, 2 showed esophageal dysmotility characterized by tertiary contractions, and 2 patients were found to have gastroesophageal reflux disease on esophagram. Of note, 8 out of 27 patients underwent esophageal biopsies, of which 6 showed normal histology, however 3 of those patients were found to have structural abnormalities on esophagram. Esophageal biopsies were not taken in 19/27 patients, of whom 14 had abnormal findings on barium swallow study. Conclusion: Per ASGE guidelines, EGD is considered first-line for evaluation of dysphagia unless contraindicated. Barium swallow with a 13mm pill is another valuable diagnostic modality especially in patients with a normal EGD. Our study showed that barium swallow identified potential etiologies of dysphagia in 66.7% of patients with grossly normal EGD, which led to further work-up and/or treatment. We discovered structural abnormalities on barium swallow in 50% of patients with grossly and histologically normal EGD. Esophagram proved to be a helpful adjunct to EGD with biopsy in evaluating dysphagic patients, emphasizing its importance as a part of the diagnostic algorithm.Table 1.: Patient Demographics and Barium Swallow Study Results (N=27)

A CASE OF BILATERAL PNEUMOTHORACES, PNEUMOMEDIASTINUM, PNEUMOPERITONEUM, SUBCUTANEOUS EMPHYSEMA AFTER PERORAL ENDOSCOPIC MYOTOMY PROCEDURE

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic surgery. It is a relatively safe procedure, with 8% of reported adverse events. These include pneumoperitoneum, subcutaneous emphysema, pneumothorax, and gastroesophageal reflux. However, the occurrence of bilateral pneumothoraces, pneumomediastinum pneumoperitoneum,pneumoretroperitoneum with subcutaneous emphysema in the same patient is a rare occurence. CASE PRESENTATION: Our case depicts a 60-year-old female with a history of dyslipidemia, mild intermittent asthma, gastroesophageal reflux disease who presented with complaints of worsening epigastric pain for one year. She also reported occasional episodes of chest tightness along with odynophagia and dysphagia to both solids and liquids. Patient underwent fluoroscopic imaging of esophagus that revealed a large-sized hiatal hernia, patulous mid to upper esophagus with non-propulsive tertiary contractions involving the distal third portion of the esophagus. Esophagogastroduodenoscopy showed Barrett's esophagus with low-grade dysplasia, a large hiatal hernia, and gastroparesis in the fundus. A working diagnosis of distal esophageal spasm was confirmed with manometry. She thus underwent a POEM procedure for diffuse esophageal spasm. Patient reported dyspnea with pleuritic chest pain in the immediate post operative period. A chest X-ray, later a Computerized tomography scan was obtained showing large bilateral pneumothoraces, pneumomediastinum, subcutaneous emphysema along with intraperitoneal and retroperitoneal air. Her vital signs were stable; there was reduced intensity of breath sounds bilaterally on chest auscultation, with remaining normal systemic physical examination. Patient underwent bilateral tube thoracostomies. A contrast evaluation was performed for the integrity of the gastroesophageal junction which was negative for extravasation. Over the course of the hospitalization, there was complete resolution of the pneumothoraces, pneumomediastinum and pneumoperitoneum and pneumoretroperitoneum. Thereupon, bilateral chest tubes were removed. DISCUSSION: Gas related complications are seen after POEM procedure because of gas insufflation into esophageal wall during the procedure and the close proximity to pleura and mediastinal structures, leading to gas leak. To minimize the risk of complications, the use of insufflation and CO2 flow should be minimized especially when the endoscope is within submucosal tunnel. Particular attention to the changes in airway pressures and hemodynamic changes allow early detection and prompt intervention during the procedure. Tension pneumothorax and tension pneumopericardium are life-threatening complications CONCLUSIONS: Our case highlights the realm of complications after POEM procedure. Endoscopists, anesthesiologists, and perioperative clinicians must be aware of the complications. Reference #1: Khashab MA, El Zein M, Kumbhari V, et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc. 2016;83(1):117–125. Reference #2: Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). DISCLOSURES: No relevant relationships by Nafiisah Rajabalee, source=Web Response No relevant relationships by Roberto Solis, source=Web Response No relevant relationships by Rishitha Yelisetti, source=Web Response

A133 DEVELOPMENT OF TYPE 3 ACHALASIA WITH DISTANT PANCREATIC MALIGNANCY

Abstract Background Pseudoachalasia is often caused by malignant involvement at the gastroesophageal junction (GEJ) leading to dysphagia. Aims We describe a case of type 3 achalasia presenting in a woman with metastatic pancreatic cancer with no direct involvement at the GEJ, fundus or cardia. Methods A case report and literature review were performed. Results A 53-year-old woman presented with a 2-month-history of progressive abdominal pain, nausea and vomiting with a 30-pound weight loss. She had a remote history of breast cancer in remission after surgery and chemoradiation. On presentation, she denied chest pain, reflux, dysphagia or odynophagia. Abdominal exam revealed focal epigastric tenderness and jaundice. Abdominal CT showed a 6.7 x 5.8 cm conglomerate mass involving the hepatic hilum, pancreatic head, duodenum, common bile duct, and portal vein with gastric outlet and biliary obstruction. This mass was confirmed to be a pancreatic adenocarcinoma on pathology. She then underwent nasogastric tube decompression. Initial esophagogastroduodenoscopy (EGD) confirmed a stenotic area at the distal duodenal cap. A duodenal stent and common bile duct stent were placed during a second EGD. The esophagus and GEJ were unremarkable on both endoscopic exams. She was started on chemotherapy with gemcitabine and abraxane. Two weeks after her stent placement, she rapidly developed severe retrosternal squeezing discomfort and choking occurring with swallowing. CT chest and abdomen were negative for any intrathoracic and diaphragmatic involvement with stability of the mass. A barium swallow study demonstrated tertiary contractions in the thoracic esophagus with marshmallow hold-up in the distal esophagus. She then underwent a high-resolution esophageal manometry study that demonstrated an elevation of integrated residual pressure (IRP) of the lower esophageal sphincter (LES) and absence of peristalsis, with the distal 2/3rds of the esophagus showing a simultaneous and prolonged pressure front consistent with type 3 achalasia, Chicago classification v3.0 [Figure 1]. All contractions had a distal contractile integral (DCI) of &amp;gt;8000 mmHg-cm-s. She experienced significant symptom improvement with pinaverium bromide, a gut-specific calcium channel antagonist. A review of the literature revealed that there have been 4 English-language cases published on pseudoachalasia associated with pancreatic cancer, with all cases describing direct infiltration of pancreatic cancer in the GEJ, cardia or fundus with manometric features of type I achalasia. Conclusions We report the first case of type 3 achalasia with no evidence of direct malignant infiltration at the GEJ on radiographic and endoscopic evaluations. Possible mechanisms to explain this phenomenon include paraneoplastic antibody-mediated impairment of enteric neurons that decrease nitric oxide availability, or microscopic disease involvement at the GEJ. Funding Agencies None

Megaesophagus in Mule

Background: Megaesophagus is a chronic dilation of the esophagus rarely found in horses. It’s a non-specific disease that is associated with several causes, and esophageal hypomotility is the dysfunction that most commonly results in organ dilation. In the literature, there are few reports of megaesophagus in horses and, to date, no cases in mule have been reported. The objective of this work is to describe a case of a donkey with thoracic megaesophagus.Case: A 16 year-old donkey, castrated male, mixed breed weighing 195 kg, was referred for clinical care with a history of 5 days of anorexia. On physical examination, apathy, cachexia, 8% dehydration, moderate enophthalmos, ptialism, bilateral nasal discharge, dry and bristling hair were observed. Due to the poor general condition, a nasogastric tube was chosen to perform enteral nutrition, however, it was not possible to progress the tube to the stomach. In order to confirm the suspicion of a possible esophageal obstruction, gastroscopy was performed, where it was possible to observe an esophageal dilation filled with bulky food located in the thoracic portion of the esophagus. In an attempt to stimulate esophageal motility, in order to promote the progression of the material present in the region of dilation, intramuscular metoclopramide was administered (two applications every 6 h), however the treatment had no effect. Due to the unfavorable prognosis and financial limitations of the owner, euthanasia was performed, which was followed by autopsy and histopathological examination. At necropsy, a marked dilation of the esophagus was observed in the thoracic portion, which was filled with approximately 500 grams of bulky food (grass). In the mucosa of this area, multiple ulcers were observed that occasionally coalesce, covered by a moderate amount of friable and yellowish-white material.Discussion: Megaesophagus is characterized by organ dilatation and enlargement, absence of peristalsis, presence of tertiary contractions and non-total or partial relaxation of the lower sphincter. Its origin can be congenital or secondary (acquired). In the congenital form, which corresponds to the hypomotility and generalized dilation of the esophagus, the main consequence is the underdevelopment of the foal after weaning. The acquired form occurs due to motor changes in the esophagus or gastroesophageal sphincter, causing passive dilation of the organ. Lupus erythematosus, polymyositis, polyneuritis, degenerative neuropathies, hypoadrenocorticism, hypothyroidism, thiamine deficiency, heavy metal poisoning (Lead and Thallium), tumors (mainly thymoma) and cervical injuries are among the main causes of secondary megaesophagus. Animals with esophageal paralysis or some type of esophageal obstruction, usually present nasal and oral reflux of saliva and may develop aspiration pneumonia, accompanied by nutritional deficiencies, weight loss, changes in normal development and the presence of esophageal ulcers. With the exception of pneumonia, the animal in the present report had all these signs. The prognosis of animals affected by megaesophagus is unfavorable. One of the ways to alleviate this disease is surgical treatment, however, complications such as dehiscence are common after esophageal surgery, mainly due to the fact that this organ does not have a serous layer, resulting in delayed healing. For this reason, euthanasia is considered in most cases. Megaesophagus is a non-specific and multifactorial disease that affects horses, and there are no reports in the literature in mules. In this case, endoscopy allowed the diagnosis to be made while still alive, however it was not possible to determine the primary cause of the disease.

1772 Novel Use of Low Dose Amitriptyline in the Prevention of Deglutition Syncope: A Case Report

INTRODUCTION: Deglutition syncope is a rare entity with approximately 100 reported cases. It is a subtype of neurocardiogenic syncope triggered by deglutition secondary to organic and functional esophageal pathology. There are limited treatment options, and here we report a case of using low-dose amitriptyline (10 mg) for deglutition syncope. CASE DESCRIPTION/METHODS: A 58 year old male with hypertension, diabetes mellitus, and peripheral neuropathy presented to gastroenterology clinic with a diagnosis of deglutition syncope. Over the preceding year, he experienced four syncopal episodes while eating, described as lightheadedness before losing consciousness for a minute. Electroencephalogram, electrocardiogram, and echocardiography were unremarkable. Tile-table test showed reflex vasovagal syncope with systolic vasodepression (63 mm Hg) without cardioinhibition. Continuous telemetry showed sinus bradycardia (50 bpm) followed by three sinus pauses up to 4 seconds and return to normal sinus rhythm during episodes of dysphagia and lightheadedness. Evaluation for dysphagia with esophagogastroduodenoscopy (EGD) was unremarkable. Esophagram showed tertiary contractions in the mid-distal esophagus. Esophageal manometry was unremarkable for dry swallows with premature contractions possibly suggestive of distal esophageal spasm (Figure 1). Patient refused repeat EGD. A diagnosis of deglutition syncope with combined cardioinhibition and vasodepression secondary to esophageal spasm was made. Pacemaker implantation was recommended for syncopal symptoms from cardioinhibition; however, the patient declined due to potential persistence of symptoms from vasodepression. Initial recommendations of dietary changes and avoidance of triggering medications were made. Calcium channel blockers and nitrates were limited by bradycardia and hypotension. Hyoscyamine provided partial relief, but pre-syncopal symptoms persisted. Low-dose amitriptyline was initiated for the potential underling etiology of esophageal spasm. After a year, the patient reported resolution syncopal symptoms and dysphagia. DISCUSSION: Deglutition syncope due to cardioinhibition and vasodepression secondary to underlying esophageal spasm was diagnosed with tilt-table testing, continuous telemetry, and esophageal manometry. Amitriptyline was chosen for its anticholinergic effects and esophageal neuromodulator properties. Low-dose amitriptyline may be considered as a preventative treatment for resistant deglutition syncope.

Opioids: A Difficult Pill to Swallow

The effect of opioids on lower gut motility resulting in bowel dysfunction is well known with a wealth of data surrounding it. However, there is surprisingly little data with regard to clinical effects of opioids on esophageal motility. In this case we present a patient who developed esophageal dysmotility as a result of opioids. A 50 year old female with a history significant for chronic abdominal pain secondary to chronic pancreatitis, presented with acute worsening abdominal pain. A CT abdomen was consistent with acute on chronic pancreatitis. Her home medications included MS Contin for her chronic pain, thus, on admission, she was started on a Hydromorphone PCA pump. Three days later, she reported acute onset of incomplete swallowing with regurgitation. A barium swallow showed prominent tertiary (nonpropulsive) contractions involving the mid and distal esophagus with delayed emptying into the stomach. A subsequent upper endoscopy did not detect any significant reason for her dysphagia. Her dysmotility was thought to be secondary to the acute increase of opioids in the setting of her chronic use. A speech pathology evaluation did not recommend any changes to her diet type. On discharge, she was scheduled for further esophageal motility testing and was also referred to a pain specialist in hopes of weaning her opioid use. There is a large range of manometric abnormalities seen in patients with dysphagia in the setting of opioid use, including impaired lower esophageal relaxation, high amplitude/velocity contractions, and simultaneous waves. Stimulation of peripheral opioid receptors have been shown to alter gastric, small bowel and colon function by affecting motility. In the lower gut, opioids act to block acetylcholine and other excitatory transmitters to inhibit propulsion as well as evoking spasm in smooth muscle by inhibiting nitric oxide. The distribution of these opioid receptors in the esophagus remains unclear. It is speculated that opioids act preferentially on nitric oxide releasing neurons in the esophagus leading to spastic esophageal motility. In one study, increased use of opioids was found to be associated with increased esophageal outflow obstruction, higher relaxation pressure, and manometric patterns similar to type III achalasia. While it is known that opioids can have deleterious effects on any part of gut motility, with the bowel the most often of concern, clinicians must be aware of effect of opioids on esophageal motility as well.

Achalasia Associated With Esophageal Intramural Pseudodiverticulosis: A Rarely Reported Condition

Intro: Esophageal intramural pseudodiverticulosis (EIP) is a benign, rare condition that most commonly presents in patients ages 50-70. It is often associated with diabetes mellitus, chronic alcoholism, malnutrition, or achalasia as depicted in the case below. It was first reported in 1960 with roughly 250 cases worldwide, and only 2 reports are associated with achalasia.Figure: Barium esophagram showing multiple classic button and flask shaped EIP in the upper esophagus.Figure: Barium esophagram depicting dilatation of the mid esophagus with tortuosity of the mid to distal portion.Case: An 87 year old male with a history diabetes and progressive dysphagia with regurgitation of solids and liquids over many years presented to the ER in septic shock secondary to aspiration pneumonia. He had endoscopy three years prior showing candidal esophagitis, epiphrenic diverticulum, and a schatzki ring. Follow-up endoscopy revealed tertiary contractions and he was prescribed a calcium channel blocker, which he did not take. Two months prior to this admission, a barium esophagram showed dilatation of the mid esophagus, several pseudodiverticula in the upper esophagus, tortuosity of the mid to distal portion, a 4.2x4.3cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, silent aspiration of contrast, incomplete emptying and regurgitation to the oropharynx. High resolution manometry was significant for esophageal aperistalsis and lower esophageal sphincter pressure indicating achalasia. He presented with aspiration before achieving outpatient management. Given the patient's age and multiple comorbidities, palliative endoscopic treatment was given with botox injection and symptomatic improvement.Figure: Barium esophagram depicting a large 4.2x4.3 cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, and regurgitation of contrast into the upper esophageal pseudodiverticula.Discussion: EIP is a rare condition caused by reactive hypertrophy and increased intramural pressure creating dilation and outpouching of the esophageal submucosal gland excretory ducts caused by a distal obstruction from chemical, infectious, or mechanical processes, such as achalasia. Dysphagia, reflux, and odynophagia are common presenting symptoms with stricture formation in up to 90% of cases. Barium esophagram shows flask or button-shaped outpouchings and may reveal dysmotility. The main goal of treatment is to correct the underlying disorder, which involved botox injection to palliate the patient's achalasia. EIP is generally benign though complications include aspiration pneumonia, candidal infection, fistulas, mediastinitis, and perforation. We present this case to raise physician awareness of this rare condition to aid in prompt diagnosis and management, in hopes of avoiding complications that result in increased patient morbidity and mortality.

Achalasia after Bariatric Roux-en-Y Gastric Bypass Surgery Reversal

Introduction: Achalasia is rare esophageal motility disorder that leads to loss of peristalsis in the distal esophagus and a failure of lower esophageal sphincter (LES) relaxation. It usually manifests as dysphagia for solids and liquids, and regurgitation of undigested food or saliva. The development of esophageal motility disorders including achalasia following bariatric surgery is still controversial and differ according to the type of surgery. Many cases of achalasia as a consequence of gastric band placement have been described. However, the development of achalasia and other motility disorders after Roux-en-Y gastric bypass (RYGB) are rare and only reported in some case reports. Case report: 70-year-old female patient with past medical history of morbid obesity presented to with complains of persistent nausea and regurgitation for the last 1 month. Her surgical history was significant for a laparoscopic cholecystectomy in addition to a laparoscopic Roux-en-Y gastric bypass (RYGB) approximately 2 years ago. Her surgery was revised 2 months prior to her presentation. Physical examination showed the wound of her recent surgery with no evidence of discharge or poor healing. Initial laboratory workup including complete blood count, comprehensive metabolic panel, and stool analysis were unremarkable. CT-scan of the abdomen and pelvis with contrast showed enteric contrast within the dilated distal esophagus, and was suspicious for mild stricture at gastro-esophageal sphincter (GES). Esophagogastroduodenoscopy showed a tortuous and dilated esophagus with large amounts of thick secretions. No strictures or stenosis was noted. Barium study was done afterward and showed persistent narrowing of the GES with a moderately dilated esophagus proximally and tertiary esophageal contractions. It was suggestive of achalasia. An outpatient manometry study revealed high LES pressure with abnormal relaxation, in addition to aperistalsis and those findings were consistent with type II achalasia. She was referred to surgery for possible laparoscopic heller's myotomy. Conclusion: We are presenting a rare case of achalasia after RYGB. As of our best knowledge there are only 3 cases reported for achalasia after RYGB and this is the first case described after revision of RYGB. The exact pathophysiology is not clearly understood, but local trauma due to surgery may play a role. An important consideration in similar cases is to rule out stenosis of the gastrojejunostomy.Figure 1Figure 2Figure 3

Manometry and radiology

The relationship between radiological and manometric findings in esophageal motility disorders is poorly understood. Therefore, 20 subjects (4 normal; 13 diffuse spasm; 3 other motility disorders) were studied using synchronous manometry and videofluoroscopy with alternate 5-ml and 10-ml barium swallows. A total of 181 swallows were analyzed. Concordance between manometry and fluoroscopy was excellent for individual swallows (98%), groups of 5 swallows (97%), and final diagnoses (90%). Contraction onset intervals less than 0.8 s apart over 5 cm (velocity greater than 6.25 cm/s) were critical in determining abnormal bolus transit (98% sensitivity and positive predictive value). Radiologically, segmental tertiary activity (complete luminal obliteration) was always associated with disrupted primary peristalsis, but nonsegmental tertiary activity was often seen with normal bolus transit and did not have a specific manometric correlate. Four patterns of interrupted peristalsis radiologically were found--segmental tertiary contractions, a generalized esophageal contraction, absence of motor activity, or discoordinated "to-and-fro" movement. Surprisingly, nearly complete barium clearance occurred by the first two mechanisms in two thirds of swallows. Thus, the authors believe radiology and manometry are both excellent studies for identifying abnormal esophageal peristalsis. In difficult cases, these tests give complementary information because radiology assesses bolus movement while manometry provides quantitative pressure data.

Primary versus secondary achalasia: New signs on barium esophagogram.

Aim:To investigate new signs on barium swallow that can differentiate primary from secondary achalasia.Materials and Methods:Records of 30 patients with primary achalasia and 17 patients with secondary achalasia were reviewed. Clinical, endoscopic, and manometric data was recorded. Barium esophagograms were evaluated for peristalsis and morphology of distal esophageal segment (length, symmetry, nodularity, shouldering, filling defects, and “tram-track sign”).Results:Mean age at presentation was 39 years in primary achalasia and 49 years in secondary achalasia. The mean duration of symptoms was 3.5 years in primary achalasia and 3 months in secondary achalasia. False-negative endoscopic results were noted in the first instance in five patients. In the secondary achalasia group, five patients had distal esophageal segment morphology indistinguishable from that of primary achalasia. None of the patients with primary achalasia and 35% patients with secondary achalasia had a length of the distal segment approaching combined height of two vertebral bodies. None of the patients with secondary achalasia and 34% patients with primary achalasia had maximum caliber of esophagus approaching combined height of two vertebral bodies. Tertiary contractions were noted in 90% patients with primary achalasia and 24% patients with secondary achalasia. Tram-track sign was found in 55% patients with primary achalasia. Filling defects in the distal esophageal segment were noted in 94% patients with secondary achalasia.Conclusion:Length of distal esophageal segment, tertiary contractions, tram-track sign, and filling defects in distal esophageal segment are useful esophagographic features distinguishing primary from secondary achalasia.

Tu1186 The Role of Integrated Relaxation Pressure Assessed by Using High Resolution Manometry in Achalasia Patients

Background: Esophageal symptoms are common in the general population, and include dysphagia, heartburn and chest pain. High-resolution manometry (HRM) is often utilized to characterize motility disorders as contributors to these symptoms. Studies using HRM have been largely performed at specialized tertiary medical centers, and thus could be influenced by referral bias. To date, there are no studies evaluating the type and frequency ofmotility abnormalities in patients presenting in a community setting.Methods: A retrospective review of 100 consecutive HRM studies for adult patients was performed at a single, community-based medical center in Rockford, IL from January 2012 through December 2013. The Chicago Classification was applied to characterize motility findings. EGD and esophagram studies performed within 2 months of HRM were reviewed. Results: In this community-based study, 59% of patients who underwent HRM met major manometric criteria for esophageal abnormalities. Achalasia (I,II,III) was the most common major manometric abnormality (n=17), followed by esophagogastric junction (EGJ) outflow obstruction (n=10), and hypercontractile esophagus, including jackhammer (n=7) and nutcracker (n= 1). Weak peristalsis with large defects (n=3) and small defects (n=8) accounted for the most common minor criteria. Patients who underwent HRM most commonly presented with dysphagia (54%), followed by heartburn (25%) and chest pain (16%).Manometric abnormalities were present in 42/58 (72%) presenting with dysphagia, 14/26 (54%) with heartburn, and 7/17 (41%) with chest pain. Dysphagia to liquids, when noted by clinicians, was associated withmanometric abnormalities 72% of the time. In those patients withmanometric abnormalities, findings of abnormal esophagram (radiologist observed tertiary contractions, presbyesophagus, spasm, or dysmotility) were seen in 28/35 (80%) patients (SEN 80%; SPEC 36%; ACC 67%). Abnormal EGD findings (gastroenterologist observed dysmotility and/or spasm, significant retained food, tight LES, or suspected achalasia) were seen in 33/ 54 (61%) patients (SEN 61%; SPEC 65%; ACC 63%). In those HRM(abnormal) patients that received both EGD and esophagram, the presence of concurrent abnormalities in these tests occurred in only 17/35 (49%) patients (SEN 49%; SPEC 71%; ACC 55%).Conclusions: To our knowledge, this is the first community-based study to characterize esophageal symptoms using high-resolution esophageal manometry. Manometric abnormalities were common, seen in nearly 60% of patients, and included achalasia (28% of all abnormalities),

Tu1185 Community-Based Characterization of Esophageal Motility Disorders Using High-Resolution Manometry (HRM) in Symptomatic Adults

Background: Esophageal symptoms are common in the general population, and include dysphagia, heartburn and chest pain. High-resolution manometry (HRM) is often utilized to characterize motility disorders as contributors to these symptoms. Studies using HRM have been largely performed at specialized tertiary medical centers, and thus could be influenced by referral bias. To date, there are no studies evaluating the type and frequency ofmotility abnormalities in patients presenting in a community setting.Methods: A retrospective review of 100 consecutive HRM studies for adult patients was performed at a single, community-based medical center in Rockford, IL from January 2012 through December 2013. The Chicago Classification was applied to characterize motility findings. EGD and esophagram studies performed within 2 months of HRM were reviewed. Results: In this community-based study, 59% of patients who underwent HRM met major manometric criteria for esophageal abnormalities. Achalasia (I,II,III) was the most common major manometric abnormality (n=17), followed by esophagogastric junction (EGJ) outflow obstruction (n=10), and hypercontractile esophagus, including jackhammer (n=7) and nutcracker (n= 1). Weak peristalsis with large defects (n=3) and small defects (n=8) accounted for the most common minor criteria. Patients who underwent HRM most commonly presented with dysphagia (54%), followed by heartburn (25%) and chest pain (16%).Manometric abnormalities were present in 42/58 (72%) presenting with dysphagia, 14/26 (54%) with heartburn, and 7/17 (41%) with chest pain. Dysphagia to liquids, when noted by clinicians, was associated withmanometric abnormalities 72% of the time. In those patients withmanometric abnormalities, findings of abnormal esophagram (radiologist observed tertiary contractions, presbyesophagus, spasm, or dysmotility) were seen in 28/35 (80%) patients (SEN 80%; SPEC 36%; ACC 67%). Abnormal EGD findings (gastroenterologist observed dysmotility and/or spasm, significant retained food, tight LES, or suspected achalasia) were seen in 33/ 54 (61%) patients (SEN 61%; SPEC 65%; ACC 63%). In those HRM(abnormal) patients that received both EGD and esophagram, the presence of concurrent abnormalities in these tests occurred in only 17/35 (49%) patients (SEN 49%; SPEC 71%; ACC 55%).Conclusions: To our knowledge, this is the first community-based study to characterize esophageal symptoms using high-resolution esophageal manometry. Manometric abnormalities were common, seen in nearly 60% of patients, and included achalasia (28% of all abnormalities),

Correlation between the radiological observation of isolated tertiary waves on an esophagram and findings on high-resolution esophageal manometry.

Barium esophagrams are a frequently performed test, and radiological observations about potential abnormal esophageal motility, such as tertiary contractions, are commonly reported. We sought to assess the correlation between tertiary waves, and in particular isolated tertiary waves, on esophagrams and findings on non-synchronous high-resolution esophageal manometry. We retrospectively reviewed reports of esophagrams performed at a tertiary referral center and identified patients in whom tertiary waves were observed and a high-resolution esophageal manometry had been performed. We defined two groups; group 1 was defined as patients with isolated tertiary waves, whereas group 2 had tertiary waves and evidence of achalasia or an obstructing structural abnormality on the esophagram. We collected data on demographics, dysphagia score, associated findings on esophagram, and need for intervention. We reviewed the reports of 2100 esophagrams of which tertiary waves were noted as an isolated abnormality in 92, and in association with achalasia or a structural obstruction in 61. High-resolution manometry was performed in 17 patients in group 1, and five had evidence of a significant esophageal motility disorder and 4 required any intervention. Twenty-one patients in group 2 underwent manometry, and 18 had a significant esophageal motility disorder. An isolated finding of tertiary waves on an esophagram is rarely associated with a significant esophageal motility disorder that requires intervention. All patients with isolated tertiary waves who required intervention had a dysphagia to liquids. Tertiary contractions, in the absence of dysphagia to liquids, indicate no significant esophageal motility disorder.

Videofluoroscopic swallowing study: esophageal alterations in patients with dysphagia.

Videofluoroscopic swallowing study is a dynamic exam and allows the evaluation of the complete swallowing process. However, most published studies have only reported alterations in the oropharynx and pharyngoesophageal transition, leaving the analysis of the esophagus as a secondary goal. The goal of this study was to investigate the prevalence of alterations in the esophageal phase thorough videofluoroscopic swallowing study in patients with dysphagia. Consecutive patients with dysphagia who underwent videofluoroscopic swallowing study including esophageal analysis between May 2010 and May 2012 had their exams retrospectively reviewed. Patients were classified into two groups: Group I - without a pre-established etiological diagnosis and Group II - with neurological disease. During the exam, the patients ingested three different consistencies of food (liquid, pasty and solid) contrasted with barium sulfate and 19 items were analyzed according to a protocol. The esophageal phase was considered abnormal when one of the evaluated items was compromised. Three hundred and thirty-three (n = 333) consecutive patients were studied - 213 (64%) in Group I and 120 (36%) in Group II. Esophageal alterations were found in 104 (31%) patients, with a higher prevalence in Group I (36.2%), especially on the items esophageal clearance (16.9%) and tertiary contractions (16.4%). It was observed that 12% of individuals in Group I only presented alterations on the esophageal phase. Evaluation of the esophageal phase of swallowing during videofluoroscopic swallowing study detects abnormalities in patients with cervical dysphagia, especially in the group without pre-established etiological diagnosis.