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1.
Cureus ; 16(7): e65623, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-39205784

RESUMEN

Achalasia is a chronic and rare disorder of esophageal motility. It is characterized by spastic or absent esophageal contractions and impairment of relaxation of the lower esophageal sphincter. Treatment modalities include smooth muscle-relaxing medications, botulinum toxin injections to lower the esophageal sphincter, pneumatic dilatation, and surgical interventions. Pneumatic dilatation is deemed to be an effective treatment option and is the most widely used non-surgical intervention. We designed this prospective study to look for any possible correlation between balloon pressure used in pneumatic dilatation, manometric findings, and patient characteristics. And to find any possible association between the need for repeat pneumatic dilatations and factors like gender, age, duration of symptoms, Eckardt score, daily retrosternal pain, manometric findings, and balloon pressures. Thirty-one patients with confirmed achalasia were enrolled in the study. All of these patients underwent pneumatic dilatation. Pearson's correlation coefficient was found to be 0.234 (p-value 0.23) between the required balloon pressure and integrated relaxation pressure (IRP). Six of these patients required repeat pneumatic dilatations. No statistically significant association was noted between the need for repeat intervention and gender, age over 40, age under 20, Eckardt score over 10, daily chest pain, duration of symptoms over two years, and IRP over 30 mmHg. In conclusion, it could be said that pneumatic dilatation does not carry a 100% success rate, and repeat sessions are needed in many of the patients with achalasia. So, long-term follow-up is crucial. Managing expectations and making a realistic plan with proper informational care is important at the beginning of treatment.

2.
Diagnostics (Basel) ; 14(14)2024 Jul 09.
Artículo en Inglés | MEDLINE | ID: mdl-39061603

RESUMEN

Gastroesophageal reflux disease (GERD), a prevalent clinical condition, is often attributed to aberrant esophageal motility, leading to gastric content reflux and associated symptoms or complications. The rising incidence of GERD presents an escalating healthcare challenge. Endoscopic and esophageal reflux monitoring can provide a basis for the diagnosis of patients with gastroesophageal reflux disease, but when the diagnostic basis is at an inconclusive value, some additional supportive evidence will be needed. Advanced technology is the key to improving patient diagnosis, accurate assessment, and the development of effective treatment strategies. High-resolution esophageal manometry (HREM) and endoscopic functional lumen imaging probe (EndoFLIP) represent the forefront of esophageal motility assessment. HREM, an evolution of traditional esophageal manometry, is considered the benchmark for identifying esophageal motility disorders. Its widespread application in esophageal dynamics research highlights its diagnostic significance. Concurrently, EndoFLIP's emerging clinical relevance is evident in diagnosing and guiding the treatment of coexisting esophageal motility issues. This review integrates contemporary research to delineate the contributions of HREM, EndoFLIP, and novel technologies in GERD. It examines their efficacy in facilitating an accurate diagnosis, differentiating similar gastrointestinal disorders, quantifying the extent of reflux, assessing the severity of the disease, forecasting patient responsiveness to proton pump inhibitor therapy, and guiding decisions for surgical interventions. The overarching aim is to deepen the understanding of GERD's underlying mechanisms and advance the formulation of holistic, efficacious treatment approaches.

3.
Neurogastroenterol Motil ; : e14868, 2024 Jul 25.
Artículo en Inglés | MEDLINE | ID: mdl-39051711

RESUMEN

BACKGROUND: The straight leg raise (SLR) maneuver, often performed during esophageal manometry, requires patients to lift their leg(s) to augment intraabdominal pressure (IAP). Diverse techniques have been applied for SLR. This study aimed to evaluate and compare the effects of SLR between single and double leg raises. METHODS: During esophageal manometry, patients were asked to raise one leg, followed by elevating both legs. The efficacy of SLR for (1) detecting hiatal hernia, (2) increasing IAP, and (3) predicting gastroesophageal reflux disease (GERD) with intraesophageal pressure (IEP) was assessed. The value of change in impedance to indicate reflux during SLR in predicting esophageal acid exposure was investigated. KEY RESULTS: The leg raise procedures were performed in 86 patients undergoing high-resolution esophageal manometry. Both the single and double leg raises exhibited a higher hiatal hernia detection rate compared to the landmark (p = 0.008 and 0.005, respectively). Double leg raise was more effective in raising IAP by >50% compared to single leg raise (100% vs. 65.1%, p < 0.001), increasing yield by 53.6%. The change in IAP showed a positive correlation with the change in IEP during double leg raise (r = 0.31; p = 0.004), higher than that for single leg raise (r = 0.23; p = 0.03). Lower intraesophageal impedance during SLR was associated with AET > 6% with double leg raise (1.5 kΩ vs. 2.5 kΩ, p = 0.04). CONCLUSIONS & INFERENCES: Our study demonstrates the efficacy of both single and double leg raise maneuvers during HREMI in increasing hiatal hernia detection and possible value in predicting GERD. The double leg raise resulted in a higher rate of effective increase in IAP, potentially enabling more patients to undergo effective SLR during HREMI.

4.
Neurogastroenterol Motil ; 36(8): e14826, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38873936

RESUMEN

BACKGROUND: Diabetes Mellitus (DM) is known to induce a wide range of harmful effects on several organs, notably leading to ineffective esophageal motility (IEM). However, the relationship between DM and IEM is not fully elucidated. We aimed to determine the relationship between DM and IEM and to evaluate the impact of DM's end organ complications on IEM severity. METHODS: A multicenter cohort study of consecutive patients undergoing high-resolution esophageal manometry (HREM) was performed. We reviewed medical records of patients diagnosed with IEM using HREM, encompassing data on demographics, DM history, antidiabetic and other medications as well as comorbidities. KEY RESULTS: Two hundred and forty six subjects met the inclusion criteria. There was no significant difference in any of the HREM parameters between diabetics and nondiabetics. Out of 246 patients, 92 were diabetics. Diabetics with neuropathy presented a significantly lower distal contractile integral (DCI) value compared to those without neuropathy (248.2 ± 226.7 mmHg·cm·sec vs. 375.6 ± 232.4 mmHg·cm·sec; p = 0.02) Similarly, the DCI was lower in diabetics with retinopathy compared to those without retinopathy (199.9 ± 123.1 mmHg·cm·sec vs. 335.4 ± 251.7 mmHg·cm·sec; p = 0.041). Additionally, a significant difference was observed in DCI values among DM patients with ≥2 comorbidities compared to those without comorbidities (224.8 ± 161.0 mmHg·cm·sec vs. 394.2 ± 243.6 mmHg·cm·sec; p = 0.025). Around 12.6% of the variation in DCI could be explained by its linear relationship with hemoglobin A1c (HbA1c), with a regression coefficient (ß) of -55.3. CONCLUSION & INFERENCES: DM is significantly associated with IEM in patients with neuropathy, retinopathy, or multiple comorbidities. These results are pivotal for tailoring patient-specific management approaches.


Asunto(s)
Complicaciones de la Diabetes , Trastornos de la Motilidad Esofágica , Manometría , Humanos , Trastornos de la Motilidad Esofágica/fisiopatología , Trastornos de la Motilidad Esofágica/epidemiología , Trastornos de la Motilidad Esofágica/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Anciano , Complicaciones de la Diabetes/epidemiología , Complicaciones de la Diabetes/fisiopatología , Estudios de Cohortes , Neuropatías Diabéticas/fisiopatología , Neuropatías Diabéticas/epidemiología , Diabetes Mellitus/epidemiología , Adulto , Estudios Retrospectivos
5.
Neurogastroenterol Motil ; 36(9): e14839, 2024 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-38837280

RESUMEN

BACKGROUND AND PURPOSE: Ineffective esophageal motility (IEM) is the most frequently diagnosed esophageal motility abnormality and characterized by diminished esophageal peristaltic vigor and frequent weak, absent, and/or fragmented peristalsis on high-resolution esophageal manometry. Despite its commonplace occurrence, this condition can often provoke uncertainty for both patients and clinicians. Although the diagnostic criteria used to define this condition has generally become more stringent over time, it is unclear whether the updated criteria result in a more precise clinical diagnosis. While IEM is often implicated with symptoms of dysphagia and gastroesophageal reflux disease, the strength of these associations remains unclear. In this review, we share a practical approach to IEM highlighting its definition and evolution over time, commonly associated clinical symptoms, and important management and treatment considerations. We also share the significance of this condition in patients undergoing evaluation for anti-reflux surgery and consideration for lung transplantation.


Asunto(s)
Trastornos de la Motilidad Esofágica , Manometría , Humanos , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/fisiopatología , Trastornos de la Motilidad Esofágica/terapia , Manometría/métodos , Reflujo Gastroesofágico/fisiopatología , Reflujo Gastroesofágico/diagnóstico
6.
J Can Assoc Gastroenterol ; 7(3): 238-245, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-38841142

RESUMEN

Background: The extent of disease severity remains unclear among CYP2C19 rapid and ultra-rapid metabolizers with refractory symptoms of gastroesophageal reflux disease (GERD) on chronic proton-pump inhibitors (PPIs). Aims: To determine the impact of CYP2C19 metabolizer status in relation to chronic PPI therapy with a focus on the extent of esophageal inflammation, acid exposure, and motor function. Methods: This retrospective study included 54 patients with refractory GERD symptoms who underwent CYP2C19 genotyping for PPI metabolism, esophagogastroduodenoscopy, ambulatory pH study, and high-resolution esophageal manometry. Patients were divided into three groups: normal metabolizer (NM) group, intermediate metabolizer/poor metabolizer (IM/PM) group, and rapid metabolizer/ultra-rapid metabolizer (RM/UM) group. The Chi-square test was used to analyze categorical variables, and one-way ANOVA for comparing means. Results: Rapid metabolizer/ultra-rapid metabolizer (RM/UM) group more frequently had either Los Angeles grade C or D GERD (7/19, 36.8% vs 1/21, 4.8%, P = 0.011) and metaplasia of the esophagus (9/19, 47.4% vs 2/21, 9.5%, P = 0.007) when compared to the NM group. RM/UM group were more frequently offered dilatation for nonobstructive dysphagia (8/19, 42.1% vs 3/21, 14.3%, P = 0.049) and more exhibited a hypotensive lower esophageal sphincter (LES) resting pressure compared to the NM group (10/19, 52.6% vs 4/21, 19%, P = 0.026). All three groups exhibited comparable DeMeester scores when PPIs were discontinued 72 hours before the ambulatory pH study. Conclusion: CYP2C19 RMs and UMs on chronic PPI with refractory GERD symptoms exhibited greater esophageal mucosal inflammation, as observed both endoscopically and histologically, and more were found to have hypotensive LES resting pressures and more were offered esophageal dilatation.

7.
Cureus ; 16(5): e59444, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38826939

RESUMEN

Background and objective Achalasia cardia is a primary esophageal motility disorder, and the etiopathology of this disease's progression is not known. Moreover, autonomic dysfunction has not been studied in different types of achalasia. In light of this, we aimed to address this lack of data in this study. Methods The diagnosis of achalasia was done using high-resolution esophageal manometry (HRM)-based Chicago classification v4.0. Autonomic function tests (AFT) such as the head-up tilt test, deep breathing test (DBT), Valsalva maneuver (VM), handgrip test (HGT), and cold pressor test (CPT), as well as the heart rate variability (HRV) test, were performed among the cohort and the results were compared with those of 39 age- and sex-matched healthy controls. Results AFT and HRV tests were done on 62 patients (30 achalasia type I, 28 type II, and 4 type III) and compared with 39 age- and sex-matched healthy controls. The mean duration of symptoms, high Eckardt score, and dysphagia were most common in type I achalasia, followed by type II and III. The results of AFT showed a generalized loss of parasympathetic and baroreflex-independent sympathetic reactivity in all types of achalasia. However, baroreflex-dependent cardiovascular adrenergic reactivity was normal. Regarding cardiac autonomic tone, there was a loss of parasympathetic and sympathetic influence, but sympathovagal balance was maintained. The severity of the loss of autonomic functions was higher in type I, followed by type II. Conclusions In all types of achalasia, parasympathetic reactivity, baroreflex-independent sympathetic reactivity, and cardiac autonomic tone were lower compared to healthy controls, and the severity of dysfunction increased during the progression of the disease from type II to type I.

8.
Dis Esophagus ; 2024 Jun 11.
Artículo en Inglés | MEDLINE | ID: mdl-38857460

RESUMEN

High-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016-2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences.

9.
Artículo en Inglés | MEDLINE | ID: mdl-38759824

RESUMEN

Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.

10.
Neurogastroenterol Motil ; 36(8): e14824, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38775182

RESUMEN

BACKGROUND: High-resolution esophageal manometry (HREM) is the gold standard test for esophageal motility disorders. Nasopharyngeal airway-assisted insertion of the HREM catheter is a suggested salvage technique for failure from the inability to pass the catheter through the upper esophageal sphincter (UES). It has not been demonstrated that the nasopharyngeal airway improves procedural success rate. METHODS: Patients undergoing HREM between March 2019 and March 2023 were evaluated. Chart review was conducted for patient factors and procedural success rates before and after use of nasopharyngeal airway. Patients from March 2019 to May 2021 did not have nasopharyngeal airway available and were compared to patients from May 2021 to March 2023 who had the nasopharyngeal airway available. KEY RESULTS: In total, 523 HREM studies were conducted; 234 occurred prior to nasopharyngeal airway availability, and 289 occurred with nasopharyngeal airway availability. There was no difference in HREM catheter UES intubation rates between periods when a nasopharyngeal airway attempt was considered procedural failure (85% vs. 85%, p = 0.9). Nasopharyngeal airway use after UES intubation failure lead to improved UES intubation rates (94% vs. 85%, p < 0.01). Thirty-six patients that failed HREM catheter UES intubation had the procedure reattempted with a nasopharyngeal airway, 30 (83%) of which were successful. The nasopharyngeal airway assisted catheter UES intubation for failures attributed to nasal pain and hypersensitivity, gagging, coughing, and pharyngeal coiling. CONCLUSIONS & INFERENCES: Utilization of the nasopharyngeal airway increased rates of UES intubation. When HREM catheter placement through the UES fails, placement of a nasopharyngeal airway can be trialed to overcome patient procedural intolerance.


Asunto(s)
Trastornos de la Motilidad Esofágica , Manometría , Humanos , Manometría/métodos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/terapia , Anciano , Nasofaringe , Catéteres , Estudios Retrospectivos , Esfínter Esofágico Superior/fisiología
12.
Int J Gen Med ; 17: 1823-1831, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38711827

RESUMEN

Purpose: Systemic Sclerosis (SSc) is a rare connective tissue disorder characterized by autoimmunity, fibrosis, and vasculopathy that affects the skin and internal organs, including the gastrointestinal tract, particularly the esophagus. This article highlights the characteristics and clinical symptoms of esophageal involvement in patients with SSc. Patients and Methods: This study was conducted between November 2022 to August 2023, including 26 already diagnosed cases of SSc in the Department of Rheumatology and Rehabilitation and Kurdistan Center for Gastroenterology and Hepatology-Sulaymaniyah, Iraq. Esophageal involvement was investigated using esophageal manometry, esophagogastroduodenoscopy (EGD), and 24-hour impedance-pH monitoring. Results: Females were significantly predominant (P = 0.019) regarding the symptoms; 76.9% of the patients had heart burn, 76.9% dysphagia, 73.1% water brush, and 69.2% regurgitation. In total, 69.2% of the patients showed erosive gastrointestinal reflux disease (GERD) on EGD, 76.9% had decreased lower esophageal sphincter pressure (DLESP) and decreased distal esophageal peristaltic contractions (DDEPC) on esophageal manometry, and 84.6% had reflux on pH monitoring. Raynaud's phenomenon is the most common and typically the earliest clinical manifestation of SSc. The presence of erosive GERD was found to significantly increase the risk of developing dysphagia (B = 4.725, P = 0.014, OR = 3.482) and regurgitation (B = 3.521, P = 0.006, OR = 4.030). Conclusion: It is crucial to take gender-specific considerations into account when diagnosing and managing esophageal complications in patients with systemic sclerosis (SSc). Additionally, employing various diagnostic assessments to detect esophageal involvement during SSc is essential. Erosive GERD has been identified as a risk factor that contributes to the development of dysphagia and regurgitation in individuals with SSc.

13.
Tzu Chi Med J ; 36(2): 120-126, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38645779

RESUMEN

Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.

14.
Cureus ; 16(3): e56663, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38646200

RESUMEN

A 14-year-old girl with a history of asthma was hospitalized because of sudden-onset back pain around her thoracic region that spread to her chest and abdomen. She had been experiencing dysphagia and breathing difficulties for two years, especially after overeating, which often resulted in vomiting undigested food. CT imaging revealed a severely dilated esophagus narrowing at the gastroesophageal junction, suggestive of type 1 achalasia. Further testing confirmed the diagnosis, with an esophageal manometry showing a lack of esophageal contractions and sphincter relaxation. She then underwent a laparoscopic Heller myotomy with relief to her symptoms. This case underscores the rarity of pediatric-onset achalasia with significant esophageal dilation and secondary airway compression, presenting with unusual musculoskeletal and respiratory symptoms. Timely diagnosis and treatment are crucial to prevent worsening and complications.

15.
Indian J Gastroenterol ; 43(4): 740-747, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38564157

RESUMEN

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS: We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS: The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION: PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.


Asunto(s)
Dilatación , Acalasia del Esófago , Miotomía de Heller , Laparoscopía , Ensayos Clínicos Controlados Aleatorios como Asunto , Acalasia del Esófago/cirugía , Acalasia del Esófago/terapia , Humanos , Laparoscopía/métodos , Miotomía de Heller/métodos , Miotomía de Heller/efectos adversos , Dilatación/métodos , Resultado del Tratamiento , Adulto , Femenino , Masculino , Persona de Mediana Edad , Seguridad
16.
Cir Esp (Engl Ed) ; 102(6): 340-346, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-38604565

RESUMEN

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.


Asunto(s)
Acalasia del Esófago , Acalasia del Esófago/terapia , Acalasia del Esófago/cirugía , Acalasia del Esófago/diagnóstico , Humanos , Factores de Tiempo
17.
Dis Esophagus ; 37(8)2024 Jul 31.
Artículo en Inglés | MEDLINE | ID: mdl-38582609

RESUMEN

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.


Asunto(s)
Trastornos de Deglución , Endoscopía del Sistema Digestivo , Manometría , Humanos , Trastornos de Deglución/etiología , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/fisiopatología , Manometría/estadística & datos numéricos , Manometría/métodos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Endoscopía del Sistema Digestivo/estadística & datos numéricos , Endoscopía del Sistema Digestivo/métodos , Anciano , Adulto , Derivación y Consulta/estadística & datos numéricos , Esófago/fisiopatología , Esófago/patología , Modelos Logísticos
18.
Gastroenterol. hepatol. (Ed. impr.) ; 47(3): 272-285, mar. 2024. ilus, graf
Artículo en Español | IBECS | ID: ibc-231212

RESUMEN

La disfagia orofaríngea (DO) es una enfermedad con una alta prevalencia en diferentes fenotipos de pacientes. La manometría de alta resolución faringoesofágica (MARFE) con impedancia (MARFE-I) se ha convertido en los últimos años en una técnica fundamental para el mejor entendimiento de la fisiopatología de las disfunciones de la faringe y del esfínter esofágico superior (EES) en pacientes con DO. Diversos grupos de expertos han propuesto una metodología para la práctica de la MARFE-I y para la estandarización de las diferentes métricas para el estudio de las disfunciones de la motilidad faríngea y del EES basadas en el la cuantificación de 3fenómenos principales: la relajación del EES, la resistencia al flujo a través del EES y la propulsión del bolo a través de la faringe hacia el esófago. De acuerdo a las alteraciones de estas métricas, se proponen 3patrones de disfunción que permiten un abordaje terapéutico específico: a) restricción al flujo del EES con propulsión faríngea normal; b) restricción al flujo del EES con propulsión faríngea inefectiva, y c) contracción faríngea inefectiva con normal relajación del EES. Presentamos una revisión práctica de la metodología y la métrica que emplean los principales grupos de trabajo junto con la descripción de los principales patrones de disfunción de acuerdo con nuestra experiencia para poner de relevancia la utilidad de la MARFE-I en el estudio de la fisiopatología y selección de un tratamiento específico en pacientes con DO. (AU)


Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD. (AU)


Asunto(s)
Trastornos de Deglución/fisiopatología , Manometría , Esfínter Esofágico Superior/fisiopatología
19.
Curr Gastroenterol Rep ; 26(7): 173-180, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38539024

RESUMEN

PURPOSE OF REVIEW: Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO. RECENT FINDINGS: Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited. Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.


Asunto(s)
Trastornos de la Motilidad Esofágica , Unión Esofagogástrica , Manometría , Humanos , Unión Esofagogástrica/fisiopatología , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/terapia , Trastornos de la Motilidad Esofágica/fisiopatología , Trastornos de la Motilidad Esofágica/etiología , Esfínter Esofágico Inferior/fisiopatología , Esfínter Esofágico Inferior/cirugía , Miotomía/métodos
20.
Dig Dis Sci ; 69(5): 1661-1668, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38507124

RESUMEN

BACKGROUND: Motility disorders are frequently encountered in gastroenterology (GI) practice, yet a national structured training curriculum for GI fellows in motility disorders is lacking. Since GI fellowships vary considerably in opportunities for specialized esophageal motility (EM) training, novel educational technology may be leveraged to provide standardized EM curriculum to train GI fellows in esophageal manometry. METHODS: GI fellows participated in an online EM learning program at a single academic center from 2017 to 2022. Fellows answered case-based questions and were provided with evidence-based, corrective feedback related to core EM learning objectives. The primary outcome was change in knowledge and comfort in interpretation and clinical application of EM studies. RESULTS: Sixty-nine fellows actively participated in the online EM curriculum. 65 fellows completed a pre-curriculum test, and 54 fellows completed a post-curriculum test. There was a cumulative improvement between pre-curriculum test and post-curriculum test scores from 70 to 87%, respectively (p < 0.001). Fellows had a mean improvement of 19% in questions as they progressed through the curriculum. Prior to enrolling in the EM course, 26% of fellows felt comfortable in interpreting EM studies compared to 54% of fellows after completion of the program (p < 0.001). CONCLUSION: An online, technology-based curriculum was effective in educating GI fellows on core competencies of EM. Fellows demonstrated improvement in proficiency of clinically important EM studies and increased comfort in interpreting EM studies. Further studies are needed to evaluate the use of technology-based learning to widely disseminate a structured training curriculum in EM, particularly in training programs without a motility presence.


Asunto(s)
Curriculum , Trastornos de la Motilidad Esofágica , Becas , Gastroenterología , Gastroenterología/educación , Humanos , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/fisiopatología , Trastornos de la Motilidad Esofágica/terapia , Competencia Clínica , Educación de Postgrado en Medicina/métodos , Manometría , Educación a Distancia/métodos
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