Alessandra Elvevi

Usefulness of low- and high-volume multiple rapid swallowing during high-resolution manometry.

BACKGROUND It has been suggested that multiple rapid swallowing should be added to oesophageal manometry. AIM To prospectively evaluate whether 10 and 200 mL multiple rapid swallowing provide different information concerning motor function. METHODS 30 consecutive patients with oesophageal symptoms, 13 achalasia patients after successful pneumatic dilation and 19 healthy subjects performed eight 5 mL single swallows, two 10 mL and one 200 mL multiple rapid swallowing. RESULTS Almost all of the healthy subjects and two-thirds of the patients with oesophageal symptoms showed motor inhibition during both 10 and 200 mL multiple rapid swallowing. The oesophago-gastric pressure gradient was significantly higher during 200 mL multiple rapid swallowing within each group (p < 0.01), and significantly higher in the achalasia patients than in the other two groups (p < 0.0001). Presence of a contraction and increased contraction strength in comparison with single swallows were both more frequent after 10 mL than after 200 mL multiple rapid swallowing in the healthy subjects and the patients (p<0.05). CONCLUSION Motor inhibition could be similarly evaluated by means of 10 and 200 mL multiple rapid swallowing; 10 mL evaluated the after-contraction, whereas 200 mL multiple rapid swallowing was more valuable in identifying increased resistance to outflow.

Causes and treatments of achalasia, and primary disorders of the esophageal body

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high‐resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Computer simulator among experts involved in screening colonoscopy

Background In the era of screening colonoscopy, assessment of operator competence is warranted. Aim To evaluate feasibility of a computer simulator (CS) use for assessment of competence in colonoscopy by investigating performance of expert endoscopists at CS. Subjects Twenty expert endoscopists involved in screening colonoscopy. Methods Experts returned a questionnaire regarding personal practice (duration of activity, number of colonoscopies in the last year and assistance by a nurse) and performances (percentage of caecal intubation and polyp detection rate). One easy and one difficult colonoscopy were proposed at CS in randomized order. Results Participation rate was 75%. Caecal intubation rate in clinical practice was more than 90% for all experts. At CS, time to caecal intubation and number of attempts for ileal intubation were significantly lower during easy versus difficult colonoscopy (P<0.01 for both items); interestingly, percentage of mucosa explored was higher (P<0.05) during the difficult simulation. Withdrawal time ≥6 min was achieved by 40 and 33% of experts during the easy and difficult simulation, respectively. Independent of simulation difficulty, time with loop was lower (P<0.05) for experts using hands-free insertion (n = 8) compared with those using nurse assistance in their clinical practice (n = 7). No correlation was found between scores at CS and performance in clinical practice. Conclusion Scores at CS are sensitive to the rate of technical difficulty and nurse assistance during daily practice. Withdrawal time is often shorter than required for high accuracy in polyp detection. CS could be a well-accepted tool for assessment of competence.

Rapid air infusion into the oesophagus: Motor response in patients with achalasia and nonobstructive dysphagia assessed with high-resolution manometry

Background Achalasia is a neurodegenerative disorder of the oesophagus. Alteration of motor activity induced by oesophageal distension has not been explored. Objectives To investigate this function, using high-resolution Manometry. Methods This study enrolled 15 healthy subjects, 15 nonobstructive dysphagia (NOD), and 18 achalasia patients successfully treated with pneumatic dilation (six with restored peristalsis). The three groups underwent five rapid (<1 s) intraoesophageal infusions of 20-ml air boluses, followed by eight 5-ml water swallows. Results Whereas the response rate to water swallows was similar in the three groups, air infusion induced a lower response rate in achalasia (median, interquartile range: 70%, 40–100%) and, to a lesser extent, in NOD patients (100%, 60–100%) than in healthy subjects (100%, 100–100%; p < 0.001 and p = 0.06, respectively). However, the response rate was highly variable in achalasia patients irrespective of presence of peristalsis. Furthermore, the strength of motor response to air infusion when compared to water swallows was diminished in achalasia patients but not in healthy subjects and NOD. Conclusions Motor response to rapid air infusion was variably impaired in achalasia. The role of this alteration in the long-term outcome deserves evaluation.

Effect of Cold Water on Esophageal Motility in Patients With Achalasia and Non-obstructive Dysphagia: A High-resolution Manometry Study

Background/Aims Swallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry. Methods Fifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order. Results In healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively). Conclusions Our data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.

Severe chronic diarrhea and maculopapular rash: A case report

Systemic mastocytosis (SM) is a heterogeneous disease of the bone marrow characterized by abnormal growth, accumulation and activation of clonal mast cells (MCs). We report a case of SM with multi-organ involvement. A 30-year-old man presented with diarrhea, flushing, maculopapular rash with itching and weight loss. The upper and lower gastrointestinal endoscopies showed macroscopic involvement of stomach and duodenum; mucosal samples from stomach, duodenum, colon and distal ileum showed mucosal infiltration by large, spindle-shaped MCs with abnormal surface molecule expression (CD2 and CD25), a picture fully consistent with SM, according to the World Health Organization diagnostic criteria. A computed tomography scan showed diffuse lymphadenopathy, hepatosplenomegaly and diffuse small bowel involvement. Bone marrow aspirate and biopsy were diagnostic for SM; serum tryptase levels were increased (209 ng/mL, normal values < 20 ng/mL). The conclusive diagnosis was smouldering SM. There were no therapeutic indications except for treatment of symptoms. The patient was strictly followed up because of the risk of aggressive evolution.

Yield of prolonged wireless pH monitoring in achalasia patients successfully treated with pneumatic dilation

Background Gastro-oesophageal reflux disease (GORD) is a long-term complication of achalasia treatments. The aim of our study was to evaluate the yield of prolonged wireless pH monitoring in patients with successfully treated achalasia and its influence on proton pump inhibitor (PPI) use. Methods Twenty-five patients with achalasia who underwent prolonged wireless pH monitoring after a successful treatment with pneumatic dilation were enrolled. pH variables were analysed in the first 24 hours of monitoring to determine if tracings were indicative of GORD; the same variables were analysed in the following 24-hour period in order to obtain a worst-day diagnosis of GORD. PPI therapy before and after the test was recorded. Results Five out of 25 patients had GORD diagnosis during the first day of monitoring and four of them had oesophagitis at endoscopy. During the following days of monitoring four more patients had a diagnosis of GORD. Out of the 25 patients, PPIs were started after the test in six asymptomatic GORD-positive ones, whereas prescription of PPIs was stopped without detrimental effect on symptoms in three GORD-negative patients. Conclusions Prolonged wireless pH monitoring is a useful test to be added to endoscopy in order to evaluate GORD and to optimise antisecretory treatment in successfully treated achalasia patients.

Oesophageal motor function in chronic intestinal idiopathic pseudo-obstruction: A study with high-resolution manometry

BACKGROUND Chronic intestinal idiopathic pseudo-obstruction (idiopathic CIPO) is a rare heterogeneous condition for which the different phenotypes are difficult to be established. Oesophageal motility has shown to be impaired in patients with idiopathic CIPO at traditional manometry, whereas no studies have assessed it by high resolution manometry (HRM). AIMS To evaluate oesophageal motility by HRM in patients with idiopathic CIPO. METHODS 14 patients with idiopathic CIPO underwent oesophageal HRM. Multiple rapid swallows (MRS) were performed in order to evaluate contraction reserve. The Chicago Classification 3.0 was used to classify the oesophageal motility disorders. RESULTS One idiopathic CIPO patient had type-II achalasia, one aperistalsis and 12 had minor disorder of peristalsis (11 ineffective oesophageal motility and one fragmented peristalsis). These minor disorders were not significantly different from those of 50 other consecutive patients who underwent HRM for dysphagia or GERD and received the diagnosis of ineffective oesophageal motility. Three of the 12 idiopathic CIPO patients with minor disorder of peristalsis had no contraction reserve after MRS. CONCLUSIONS HRM is able to identify different grades of oesophageal motor impairment in patients with idiopathic CIPO. Presence of major oesophageal dismotility or absent contraction reserve suggest a more severe and widespread motor disorder.

Can biliary endoscopy play a role in liver disease associated to cystic fibrosis

a Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Milan, Italy b Cystic Fibrosis Reference Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Universita degli Studi di Milano, Milan, Italy c Department of Pathology, Fondazione IRCCS Ca’ Granda, Ospedale Policlinico Milano, Universita degli Studi, Milan, Italy