Laura Bognár

Gastroesophageal Reflux Disease Could Progress to Achalasia

c 2017 The Korean Society of Neurogastroenterology and Motility J Neurogastroenterol Motil, Vol. 23 No. 4 October, 2017 www.jnmjournal.org TO THE EDITOR: We read with interest the article entitled “Is Gastroesophageal Reflux Disease and Achalasia Coincident or Not” published in January 2017, by Jung and Park. The title raises a very interesting question, however, in the end, the question remains unanswered and the paper mostly focuses on the overlapping symptoms between gastroesophageal reflux disease (GERD) and achalasia, thus leading to diagnostic delay in many achlasia patients. The arguments for and against whether the coexistence of the 2 diseases is accidental or not, are poorly supported. We have previously put the question to ourselves as well, and based on our own experience and thorough review of the literature, we believe that the development of achalasia in certain GERD patients is not a coincidence, but that there may be a cause-and-effect relationship between the 2 diseases. Our surgical work team have operated on over 40 patients with achalasia in the past 15 years and in 10% of them, the etiological role of reflux arose. Similar to the fact that the human body has developed several aero-digestive reflexes to protect the airways from aspiration, we suggest that chronic acid exposure may lead to structural and functional changes in the esophagus, as, for example, to the development of achalasia. By this means, the narrowing of the distal lumen of the esophagus could be interpreted as another kind of protective mechanism of the body aiming at preventing the refluxate entering the esophagus or beyond. A convincing argument for the chronological order, and presumably, the casual relationship between reflux and achalasia is that several reports have been published describing the presence of Barrett’s esophagus among untreated achalasia patients. The most plausible explanation for this is that these patients had long-standing reflux disease before the development of achalasia. Also, several cases have been described where achalasia occured with concomitant hiatal hernia and it is well-known that hiatal hernia induces the development of GERD. Among our own untreated achalasia cases we also had one patient with concomitant Barrett’s esophagus and one with hiatal hernia. Altorjay et al reported an interesting observation after comparing muscle samples taken from the lower esophageal sphincter of reflux patients and those of a control group. They found that reflux patients had smooth muscle hypertrophy and enteric ganglionitis at the gastroesophageal junction, and they suggested that these morphological changes might result in various functional esophageal diseases. Based on these findings we assume that in certain cases GERD may progress to achalasia.

GERD: A Debated Background of Achalasia

Achalasia is a primary esophageal motility disorder of unknown etiology, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter (LES) relaxation. Available data suggest that the disease is multifactorial, but the exact initiating factors that may play a role in the development of the disease remain unclear. Case presentation: We report the case of a 65 year-old woman who had typical reflux symptoms with heartburn and regurgitation for about seven years. During the year before her admission to our clinic her reflux symptoms resolved and dysphagia developed. Endoscopy revealed esophageal dilatation with erosive esophagitis, narrowed cardia and hiatal hernia. Barium swallow test, manometry and 24 hour pH monitoring confirmed the development of achalasia with accompanying gastroesophageal reflux disease (GERD). The patient underwent laparoscopic surgery, the hiatal hernia was reconstructed and a Heller’s myotomy with a 360 degree Nissen fundoplication was performed. At the 3-year follow-up the patient was symptom free. Conclusion: Based on our experience and the review of the literature we believe that there is a cause-and-effect relationship between gastroesophageal reflux and the development of achalasia. In these cases a laparoscopic Heller’s myotomy completed with a 360 degree Nissen fundoplication should be the recommended surgical treatment to minimize the possibility of postoperative reflux disease.

Szövődmények és reoperációk laparoszkópos antirefluxműtétek után

Absztrakt A belgyogyaszati modszerekkel panasz- es tunetmentesse nem tehető gastrooesophagealis refluxbetegsegben szenvedő betegek kezelesere bevalt modszer a laparoszkopos antireflux-sebeszet. Gyakorlatot szerzett sebeszek nagy biztonsaggal vegzik a műtetet, megis fellepnek intraoperativ, korai postoperativ es kesői szovődmenyek, amelyek reoperaciot tehetnek szuksegesse. A Pecsi Tudomanyegyetem Sebeszeti Klinikajan 1998 es 2015 kozott 407 laparoszkopos antirefluxműtetet vegeztunk. A periodust ket szakaszra osztottuk. Az elsőben 1998 es 2006 kozott 241 beteget operaltunk es a vizsgalat prospektiv volt; minden diagnosztikus eljarast magunk vegeztunk. A masodik periodusban 166 beteget kezeltunk minimalisan invaziv modszerrel es az eredmenyeket retrospektive elemeztuk. Az osszbeteganyagban a ferfi/nő arany 161/246 volt. A betegek atlageletkora 53,1 ev volt. A 407 műtetet kiegeszitettuk 27 esetben ligamentum teres plasztikaval, 28 esetben halobeultetessel es negy esetben fascia lata plasztikaval, mert a hiatu...

Laparoszkópos hiatushernia-rekonstrukciót követő intraoesophagealis hálómigráció

Absztrakt Esetismertetes: A szerzők egy 68 eves beteg esetet ismertetik, akinel halobeulteteses hiatusplasztikaval kiegeszitett antirefluxműtetet kovetően negy honappal dysphagias panaszok jelentkeztek. Az elvegzett vizsgalatok a halo reszleges nyelőcsőbe penetralasat igazoltak. Halasztott surgősseggel vegzett műtet soran thoracolaparotomias feltarasbol a halot eltavolitottak, a nyelőcsovon eszlelt hosszanti lyuk es alatta egy rovid szűkulet miatt distalis nyelőcső- es proximalis gyomorresectiot vegeztek, a tapcsatorna folytonossagat jejunum-interpositum segitsegevel allitottak helyre. A harom honapos kontroll soran a beteg panaszmentes volt, es az elvegzett radiologiai vizsgalat a műtet utani normalis viszonyokat mutatta. Megbeszeles: Szamos tanulmany igazolta, hogy a nagymeretű hiatusherniak direkt varrattal tortenő zarasa magas recidiva arannyal jar. A servkiujulas megelőzese vegett szeles korben elterjedt a halobeultetessel megerősitett hiatusrekonstrukcio. Ezzel a servkiujulas incidenciaja valoban cs...

Gastroesophageal Reflux Disease Might Induce Certain—Supposedly Adaptive—Changes in the Esophagus: A Hypothesis

BackgroundThe increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.AimOur aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.MethodsBased on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker’s diverticulum, Schatzki’s ring, esophageal web, and Barrett’s esophagus).ResultsPatients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki’s ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett’s esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett’s esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.ConclusionWe believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

Achalasia following reflux disease: coincidence, consequence, or accommodation? An experience-based literature review

Achalasia is a motility disorder of the esophagus characterized by the defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter due to the degeneration of the inhibitory neurons in the myenteric plexus of the esophageal wall. The histopathological and pathophysiological changes in achalasia have been well described. However, the exact etiological factors leading to the disease still remain unclear. Currently, achalasia is believed to be a multifactorial disease, involving both extrinsic and intrinsic factors. Based on our experience and the review of literature, we believe that gastroesophageal reflux disease (GERD) might be one of the triggering factors leading to the development of achalasia. However, it is also stated that the two diseases can simultaneously appear independently from each other. Considering the large number and routine treatment of patients with GERD and achalasia, the rare combination of the two may even remain unnoticed; thus, the analysis of larger patient groups with this entity is not feasible. In this context, we report four cases where long-standing reflux symptoms preceded the development of achalasia. A literature review of the available data is also given. We hypothesize that achalasia following the chronic acid exposure of the esophagus is not accidental but either a consequence of a chronic inflammation or a protective reaction of the organism in order to prevent aspiration and lessen reflux-related symptoms. This hypothesis awaits further clinical confirmation.

Possible Predictive Markers of Response to Therapy in Esophageal Squamous Cell Cancer

The aim of the present study was to investigate the relationship between the intensity of biomarker expression and the response to radiochemotherapy in patients with advanced esophageal squamous cell cancer (ESCC). Ninety-two patients with locally advanced ESCC were examined retrospectively. Pre-treatment tumor samples were stained for proteins SOUL, Hsp 16.2, Growth Hormone-Releasing Hormone Receptor (GHRH-R) and p-Akt using immunhistochemistry methods. Kaplan-Meier curves were used to show the relationship between intensity of expression of biomarkers and clinical parameters and 3-year OS. A significant correlation was found between high intensity staining for Hsp 16.2, p-Akt and SOUL and poor response to NRCT. Application of a higher dose of radiation and higher dose of cisplatin resulted in better clinical and histopathological responses, respectively. Among the clinical parameters, the localization of the tumor in the upper-third of the esophagus and less than 10% weight loss were independent prognostic factors for increased 3-year OS. Hsp16.2, p-Akt and SOUL are predictors of negative response to NRCT, therefore these biomarkers may become promising targets for therapy. Furthermore, level of expression of p-Akt, weight loss and the localization of the tumor are significant factors in the prediction of OS in ESCC.

A gastrooesophagealis refluxbetegség nyelőcsőszövődményei: következmények vagy védekezőreakciók?

Gastroesophageal reflux disease affects more than 10% of the adult population. Most patients can be effectively treated with lifestyle changes and adequate acid-reducing therapy. However, about 10% of the patients remain symptomatic despite treatment and severe complications may develop. Interestingly, some of these complications seem to be a sort of defensive mechanism that may either alleviate the patients symptoms or prevent developing further complications. In Barretts esophagus, which can be unambigously considered as a complication of gastroesophageal reflux disease, reflux symptoms ruining the quality of life may significantly improve, since the metaplastic Barrett epithelium is much more resistent to gastric acid, than the normal epithelial lining of the esophagus. Furthermore, the motility disorders (hypertensive lower esophageal sphincter, achalasia, cricopharyngeal achalasia) and structural changes (Schatzkis ring, esophageal stricture, subglottic trachea stenosis), which develop as a complication of reflux may help to prevent aspiration that can cause new complaints and may lead to further complications. Orv Hetil. 2017; 158(20): 763-769.Absztrakt: A gastrooesophagealis refluxbetegseg a felnőtt lakossag tobb mint 10%-at erinti. A betegek nagy tobbsege eletmodbeli valtoztatasokkal es hatasos savcsokkentő szerekkel jol kezelhető. Az erintettek korulbelul 10%-a azonban a kezeles dacara panaszos marad, es naluk sulyos szovődmenyek fejlődhetnek ki. Kulonos modon a szovődmenyek egy resze vedekező jellegűnek tűnik, amivel a beteg panaszai merseklődhetnek, illetve mintha az allapot sulyosbodasanak es tovabbi szovődmenyek kialakulasanak megelőzeset celoznak. Az egyertelműen refluxszovődmenynek tekinthető Barrett-oesophagusban jelentősen merseklődhetnek az eletminőseget ronto panaszok, mert a Barrett-ham sokkal ellenallobb a gyomorsav maro hatasaval szemben, mint a nyelőcsovet normalisan belelő lapham. A refluxszovődmenykent kialakulo motilitaszavarok (hipertenziv also nyelőcsősphincter, achalasia cardiae es cricopharyngealis achalasia) es strukturalis elvaltozasok (Schatzki-gyűrű, nyelőcsőstrictura, subglotticus tracheastenosis) pedig segitenek me...