Faculty Bibliography

Although esophageal perforation complicates about 5% of pneumatic dilatations performed for achalasia, little is known about associated hospital and long-term courses. In order to assess the outcome of such patients undergoing emergency surgery for repair, records of seven patients sustaining perforation during pneumatic dilatation were compared to those of five patients undergoing elective myotomy during the same period. In perforation patients, mean intervals following the procedure were 3.6 hr to administration of antibiotics and 9.6 hr to surgery. The perforation and elective myotomy groups had similar mean durations of operation (3.8 vs 3.3 hr), intensive care stays (2 vs 1 days) and hospitalization (12 vs 11 days); perforation patients had a significantly longer mean interval from surgery to oral intake (7 vs 5 days). Postdischarge long-term outcomes were alike in the groups. It is concluded that patients with perforation from pneumatic dilatation that is recognized and treated promptly have outcomes that are comparable to those of patients who undergo elective myotomy

We present a case of respiratory compromise from mechanical compression of the trachea by the distended esophagus in a patient with achalasia. Our patient was unusual because of young age, male sex, and family history of achalasia. We review the literature on this unusual complication of achalasia

Several reports have emphasized the rarity of hiatal hernia in achalasia, despite the lack of inherent incompatibility of the two conditions and despite the relatively high frequency of hiatal hernia in the general population. We reviewed the radiographs of 71 of 94 consecutive patients with manometrically proven achalasia referred to Yale-New Haven Hospital. Unequivocal hiatal hernia was seen in 10 (14.1%) patients and was seen in nine of 35 (25.7%) patients 51 years old or more. Review of the radiographic reports from these 10 patients indicated that only two were properly recognized as showing both achalasia and hiatal hernia. All five patients who underwent pneumatic dilatation had excellent results. We conclude that hiatal hernia in achalasia is frequently unrecognized and underreported but is not rare, with a frequency probably similar to that of the general population

Well-known complications of radiation to the esophagus are acute esophagitis and strictures. Although radiologic studies have demonstrated motor abnormalities after radiation treatment, clinical aspects have not been described adequately, nor have manometric evaluations been reported. Clinical presentation of dysphagia long after treatment also has not been reported. We describe herein three patients who presented with dysphagia years after radiation therapy. Radiographic, endoscopic, histologic, and manometric studies supported our conclusion that these patients suffered from radiation-induced esophageal motor dysfunction. This report indicates the need, in the proper setting, to consider radiation-induced motor dysfunction as a cause of dysphagia even decades after radiation treatment

Ancillary manometric findings, e.g., high amplitude contractions, repetitiveness, or elevated lower esophageal sphincter (LES) pressure, have been reported in diffuse esophageal spasm (DES). However, two recent changes in DES have been noted: 1) it has been redefined as increased simultaneous contractions, with intermittent peristalsis, and 2) there has been more attention to reflux-associated DES. Therefore, our aims were to characterize the ancillary findings in currently defined DES and to determine whether these occurred in both idiopathic and reflux-associated DES. Records of 31 patients with DES (greater than 25% simultaneous contractions) were reviewed. Independent of manometry, some patients could be subclassified as idiopathic (N = 7; no heartburn; normal endoscopy or acid perfusion test) or reflux-associated (N = 10; heartburn; positive endoscopy). Both low and high LES pressures and contraction amplitudes were seen. Repetitive contractions were seen in nearly all patients, and segmental aperistalsis, dropped waves, or distally nonpropagated waves were seen in more than half. These findings were generally observed in both types of DES. This study of DES 1) confirms the high prevalence of repetitive contractions, 2) deemphasizes high LES pressure and contraction amplitude, 3) extends the findings to include other types of peristaltic dysfunction, and 4) indicates that manometric findings per se do not allow clear differentiation of idiopathic from reflux-associated DES

Compared with classic achalasia, vigorous achalasia has been defined as achalasia with relatively high esophageal contraction amplitudes, often with minimal esophageal dilation and prominent tertiary contractions on radiographs, and with the presence of chest pain. However, no study using current manometric techniques has compared manometric, radiographic, and clinical findings in vigorous and classic achalasia or questioned the usefulness of making this distinction. Fifty-four cases involving patients with achalasia whose radiographic and manometric studies were performed within 6 months of each other were available for review. Patients with vigorous achalasia (n = 17), defined by amplitude greater than or equal to 37 mm Hg, and patients with classic achalasia (n = 37), defined as amplitude less than 37 mm Hg, had substantial overlap in radiographic parameters of esophageal dilation, tortuosity, and tertiary contractions. Manometric properties of repetitive waves and lower esophageal sphincter pressure and clinical aspects of chest pain, dysphagia, heartburn, and satisfactory responses to pneumatic dilation were similar in both forms of achalasia. A separate analysis of patients with mean contraction amplitude greater than 60 mm Hg revealed similar findings. It is concluded that use of amplitude as a criterion for classifying achalasia is arbitrary and of dubious value

The symptoms and presentations of gastroesophageal reflux disease are rather numerous. These include the typical symptoms, such as heartburn, regurgitation, water brash, or dysphagia. However, reflux may also be responsible for such symptoms as hoarseness, pulmonary aspiration, or asthma. It may also be an important cause of noncardiac chest pain. Thus, gastroesophageal reflux disease may be considered a disease with more than just 'esophageal' symptoms

Utilizing the rationale that the calcium channel blocker nifedipine decreases lower esophageal sphincter pressure, we performed a double-blind, placebo-controlled, crossover trial of sublingual nifedipine in achalasia, a disorder whose treatment depends on reduction in lower esophageal sphincter pressure. Ten patients participated in this trial, completed diaries, underwent manometric determinations of lower esophageal sphincter pressure, and had testing of esophageal emptying rates by a solid-meal radionuclide method. Nifedipine, titrated to a dose of 10-30 mg before meals, was well tolerated. Compared with placebo, nifedipine significantly reduced the frequency of dysphagia, but some symptoms of dysphagia, regurgitation, or nocturnal cough were still present most days. Nifedipine significantly reduced lower esophageal sphincter pressure by 28%, a value approximately one-half that achieved by successful pneumatic dilatation or myotomy. Esophageal emptying rates, as determined by the radionuclide method, were unchanged by nifedipine. We concluded that 1) nifedipine reduces symptoms of achalasia, but substantial symptoms do remain during such therapy; 2) the suboptimal effect results from the limited, although statistically significant, effect of nifedipine on reduction of lower esophageal sphincter pressure; and 3) although we believe that nifedipine may be recommended as treatment for achalasia in the subset of patients whose overall medical condition places them at high risk for forceful dilatation or surgery, it cannot be recommended as a standard alternative to these other modalities