Luiz J. Abrahao

Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response.

Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patients wish.

Swallow induces a peristaltic wave of distension that marches in front of the peristaltic wave of contraction

Background  Current understanding is that swallow induces simultaneous inhibition of the entire esophagus followed by a sequential wave of contraction (peristalsis). We observed a pattern of luminal distension preceding contraction which suggested that inhibition may also traverses in a peristaltic fashion. Our aim is to determine the relationship between contraction and luminal distension during bolus transport.

Higher prevalence of obesity in erosive gastroesophageal reflux disease

CONTEXT Weight loss is commonly recommended as a treatment for gastroesophageal reflux; however, a relationship between excessive body weight and gastroesophageal reflux disease is not well established. OBJECTIVES To evaluate the prevalence of obesity and over-weight in patients with heartburn, with and without erosive esophagitis; to analyze the prevalence of hiatal hernia and the intensity of abnormal gastroesophageal reflux in both groups of patients, and its relation to body mass index. METHODS The data of pH monitoring of 362 individuals with heartburn were evaluated retrospectively. All patients had an upper gastrointestinal endoscopy and erosive esophagitis was defined by the presence of macroscopic erosion on the esophageal mucosa. Hiatal hernia was considered when the gastroesophageal junction was positioned 2 cm or more above the diaphragm. Patients with Barretts esophagus or esophageal peptic stenosis were excluded. The population was categorized according to body mass index as normal weight (body mass index between 20 and 24.9); over-weight (between 25 and 29.9), and obese (greater than 30). The diagnosis as well as the intensity of abnormal gastroesophageal reflux were obtained through the analysis of the results of pH monitoring in patients with and without erosive esophagitis and in the various categories of body mass index. RESULTS Among the 362 patients there were 148 (41%) with erosive esophagitis and 214 (59%) without erosive esophagitis, while the pH monitoring was abnormal in 100% and 57%, respectively. Among the 148 individuals with erosive esophagitis (61% male, median age 50 years), 41 (28%) had normal weight, 82 (55%) had over-weight and 25 (17%) were obese. There were 88 (60%) patients with hiatal hernia, which was present in 29 (71% of patients with normal weight), 45 (55% of patients with over-weight) and 14 (56% of obese individuals). In 121 patients without erosive esophagitis who had abnormal pH monitoring, diagnosed as non erosive reflux disease (38% male, median age 50 years), 51 (42%) patients had normal weight, 55 (46%) had over-weight and 15 (12%) were obese. Hiatal hernia was detected in 52 out of 121 (43%) patients and in 21 (41%) out of 51 individuals with normal weight, 24 (44%) of over-weight and 7 (47%) of obese. In the group of 93 patients without erosive esophagitis and normal pH monitoring (29% male, median age 43 years), 26 (28%) had hiatal hernia and there were 43 (46%) individuals with normal weight, 38 (41%) with over-weight and 12 (13%) were obese. The number of patients with obesity and over-weight was significantly higher in the group with erosive esophagitis compared to the ones without erosive esophagitis. The prevalence of hiatal hernia was also superior in the erosive reflux disease patients. The reflux intensity and the prevalence of hiatal hernia were similar in patients with normal weight, over-weight and obesity in the group with erosive reflux disease and non-erosive reflux disease. CONCLUSION There was a greater prevalence of obesity and over-weight in the group of patients with erosive esophagitis compared to patients with non-erosive reflux disease. There was no difference in reflux intensity measurements in any of the body mass index categories, in both groups. Although there was a major prevalence of hiatal hernia in the group of erosive reflux disease patients, this superiority was not extended to the categories of excessive weight in both groups.

Doença de Crohn gastroduodenal -- relato de quatro casos e revisão da literatura

BACKGROUND Crohns disease can affect all the gastrointestinal tract, but gastroduodenal involvement is rarely seen (0.5 to 13%). OBJECTIVES Report clinical, radiological and endoscopic findings and treatment of four patients with gastroduodenal Crohns disease and review the literature. PATIENTS AND METHODS Four patients (one male of 24 years old three females of 37, 66 and 74 years old) with epigastric pain, weight loss and low grade fever were referred to the University Hospitals of Federal University of Rio de Janeiro and Fluminese Federal University. Two had also mild intermittent diarrhea and arthritis/arthralgia and the third developed pyloric obstruction and received surgical treatment. Anemia was observed in only one (the young female). Barium x-ray studies showed aphthous ulcers in stomach and duodenum with distal ileum lesions and deformity in both. Upper gastrointestinal endoscopy revealed aphthous ulcers in stomach and geographic duodenal ulcers. Polypoid lesions and serpiginous ulcers within gastric antrum were observed in the young female. Colonoscopy was performed in two patients and disclosed an ulcerated ileitis in one and ulcerated pancolitis in other. Histopathology findings of biopsy specimens were inconclusive (granulomas were not found) and other causes of granulomatous disease were ruled out. Corticosteroids and proton pump inhibitors were started and two patients had their disease controlled. The other patient developed pyloric obstruction and had to be operated. CONCLUSIONS Gastroduodenal Crohns disease has distinct clinical, therapeutic and prognostic features. Advances in endoscopic methods and recognition of new histopathologic criteria for diagnosis have revealed an incidence higher than previously reported.

Prevalência de queixas supra-esofágicas em pacientes com doenças do refluxo erosiva e não-erosiva

BACKGROUND Respiratory, ear-nose and throat complaints, chest pain and dysphagia can be a part of clinical manifestations of gastroesophageal reflux disease. The first two are named supraesophageal manifestations of gastroesophageal reflux disease. Controversy about the prevalence of these clinical manifestations in patients with non-erosive and erosive gastroesophageal reflux disease exists. AIMS Evaluate the prevalence of supraesophageal manifestations in patients with erosive and non-erosive gastroesophageal reflux disease. METHODS Files from patients submitted to upper endoscopy, esophageal manometry and pH monitoring for the investigation of gastroesophageal reflux disease (heartburn as the chief complaint) were reviewed and respiratory and ear, nose and throat symptoms were recorded. Patients with erosive disease (grades I to III according to Savary-Miller classification) and with non-erosive disease (normal endoscopy with abnormal pH monitoring were selected. Statistical analysis included the chi-square test. RESULTS Two hundred and eighty patients fulfilled the inclusion criteria being 162 with erosive disease (70% with grade I esophagitis) and 118 with non-erosive disease. Overall, 88 patients had ear, nose and throat symptoms (31%), the more frequent were hoarseness and clearing and 42, respiratory manifestations (15%), being cough the more prevalent. In the ear, nose and throat symptoms group, 45 were erosive disease (28%) and 43 non-erosive disease (36.4%). As for the respiratory symptom group, 21 patients (13%) were erosive disease and 21 (18%) were non-erosive disease. CONCLUSION There was no difference in the prevalence of supraesophageal manifestations between patients with gastroesophageal erosive and non-erosive reflux disease.

Relação entre o tamanho de hérnia hiatal e tempo de exposição ácida esofágica nas doenças do refluxo erosiva e não-erosiva

BACKGROUND: In the last few years studies have demonstrated that hiatal hernias have an important role in the pathogenesis of reflux disease, promoting reflux by many different mechanisms, emphasizing that the larger the hiatal hernia, the higher the reflux intensity and erosive esophagitis prevalence. AIM: To correlate the size of hiatal hernias (small or large) with reflux intensity (measured by pH monitoring parameters) in patients with non-erosive and erosive reflux disease. PATIENTS AND METHODS: We reviewed pH monitoring from patients with typical reflux symptoms (heartburn) previously submitted to upper endoscopy. Reflux intensity was measured by the % of total time of pH 5 cm. RESULTS: A total of 192 patients were included, being 115 in erosive reflux disease group and 77 in non-erosive reflux disease group. In erosive reflux disease patients, there were 94 (81%) with small hiatal hernias and 21 (19%) with large ones and in non-erosive reflux disease patients there were 66 (85%) with small and 11(15%) with large hiatal hernias. In erosive reflux disease group, the %TT, %UT and %ST were of 13.1 + 7.1; 13.4 + 7.4 and 12.3 + 11.5 in small hiatal hernias and 20.2 + 12.3; 17.8 + 14.1 and 20.7 + 14.1 in large hiatal hernias, respectively (P <0,05 for %TT and %TS). In non-erosive reflux disease patients, %TT, %UT and %ST were 9.6 + 4.8; 10.8 + 6.8 and 8.6 + 7.3 in small hiatal hernias and of 14.6 + 13.3; 11.2 + 7.5 and 18.1 + 21.0 in large hiatal hernias respectively (P <0,05 for %TT and %TS). CONCLUSION: Large hiatal hernias increase acid exposure time only in supine position in erosive esophagitis patients and in non-erosive patients.

Papel dos testes provocativos esofagianos na investigação de pacientes com dor torácica de origem indeterminada

ABSTRACT - Background - Traditional methods employed in esophageal investigation of patients with chest pain of undetermined origin includes upper endoscopy, esophageal manometry and pH monitoring. These methods many times disclose abnormalities that can only be enrolled as the possible cause of chest pain. Provocative tests can reproduce pain in the laboratory, establishing its esophageal origin. Objectives - Determine the positivity of acid perfusion test, edrophonium and balloon distension in patients with chest pain of undetermined origin and compare with results of traditional exams, establishing the gain for the diagnosis of esophageal pain. Results - Forty patients with chest pain of undetermined origin (normal coronary angiography), 80% female, mean age of 54.7 years were submitted to traditional exams and provocative tests. Upper endoscopy disclosed erosive esophagitis in two (5%) and peptic ulcer in one (2.5%), esophageal manometry was abnormal in 60%. pH monitoring was abnormal in 14 (35%) with a positive symptom index in 7. Chest pain was considered of proved esophageal origin by traditional exams in 7 (17.5%) patients with a positive symptom index and of probable esophageal origin in 19 (47.5%) being 8 with gastroesophageal reflux disease and 11 abnormal esophageal motility. In 14 (35%) an esophageal origin could not be demonstrated. The acid perfusion test was positive in 10 (25%), edrophonium test in 8 (20%) and balloon distension test in 15 (37.5%) and at least one provocative test was positive in 23 (57.5%) patients. The introduction of provocative tests allowed the diagnosis of proved esophageal pain in 12 of 19 (63.1%) patients with probable esophageal pain and in 6 of 14 (42.8%) with normal or inconclusive traditional exams what represented a diagnostic gain of 45% (18/40). Two patients had negative provocative tests and a positive symptom index, making a total of 25 (62.5%) patients with proved esophageal pain.