Morris Traube

Classic and vigorous achalasia: A comparison of manometric, radiographic, and clinical findings

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.

Comparison of effects of nifedipine, propantheline bromide, and the combination on esophageal motor function in normal volunteers

Both intracellular calcium ions and neural input are important in esophageal smooth muscle contraction. The aim of this study was to compare the effects of well-tolerated doses of the calcium-channel blocker, nifedipine (20 mg sublingually/buccally) with the anticholinergic, propantheline bromide (15 mg orally) and the combination of these two agents on esophageal motor function. Seven healthy volunteers underwent manometric evaluation after nifedipine, propantheline bromide, the combination, and placebo on different days. Lower esophageal sphincter pressure decreased significantly (P<0.05 vs basal and placebo) by 32% after nifedipine, but fell only 21% after propantheline bromide. After the combination lower esophageal sphincter pressure fell by 45% (P<0.05 vs basal and placebo and nifedipine alone). Contraction amplitude in the body of the esophagus decreased significantly (P<0.05 vs basal and placebo) by 26% after propantheline bromide, but fell only 11% after nifedipine. The combination led to a decrease of 37% in contraction amplitude, but this was not significantly different from that obtained with propantheline bromide alone. No drug or combination had any effect on other manometric parameters. These data show that in the normal subjects studied with the above doses: (1) nifedipine has a greater effect than propantheline bromide on the lower esophageal sphincter; (2) propantheline bromide has a greater effect than nifedipine on esophageal contraction amplitude; and (3) the combination of nifedipine and propantheline bromide has an enhanced effect on both lower esophageal sphincter pressure and esophageal contraction amplitude.

Outcome after perforation sustained during pneumatic dilatation for achalasia

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.

Effect of Tracheotomy Tube Occlusion on Upper Esophageal Sphincter and Pharyngeal Pressures in Aspirating and Nonaspirating Patients

Abstract The biomechanics of the pharyngeal swallow in patients with a tracheotomy tube were investigated with manometry. Upper esophageal sphincter (UES) and pharyngeal pressure recordings were made with and without occlusion of the tracheotomy tube. Criteria for selection were ability to tolerate tracheotomy tube occlusion for both 5 minutes prior to and during the first manometric analysis, absence of surgery to the upper aerodigestive tract other than tracheotomy, and no history of oropharyngeal cancer or stroke. Aspiration was determined objectively by fiberoptic endoscopic evaluation of swallowing (FEES) immediately prior to manometric recording. Eleven adult individuals with tracheotomy participated; 7 swallowed successfully and 4 exhibited aspiration on FEES. The results indicated no significant effect of tracheotomy tube occlusion on UES or pharyngeal pressures in either aspirating or nonaspirating patients. It was concluded that the biomechanics of the swallow as determined by UES and pharyngeal manometric pressure measurements were not changed significantly by tracheotomy tube occlusion in aspirating or nonaspirating patients. These results support previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status.

Nonsurgical management of esophageal perforation from pneumatic dilatation in achalasia

Perforation of the esophagus is a well-described complication of pneumatic dilatation in patients with achalasia. Although successful management of these patients without surgical intervention has been reported, little follow-up data exist. We report the successful nonsurgical management of esophageal perforation after pneumatic dilatation in three patients. Manometric and radionuclide esophageal emptying studies in these patients showed satisfactory results after the dilatations despite the occurrence of perforation, and the excellent symptomatic response has been maintained during a follow-up period ranging from one to four years.

Primary oesophageal motility disorders current therapeutic concepts

SummaryVarious oesophageal manometric disorders have been associated with chest pain or dysphagia. The classic motility disorders are achalasia and diffuse oesophageal spasm. In achalasia, a disorder of aperistalsis in the oesophageal body and incomplete relaxation of the lower oesophageal sphincter, either surgical myotomy or pneumatic dilatation is an effective approach, although some investigators have suggested a role for pharmacological therapy. For the treatment of diffuse oesophageal spasm, a disorder of non-peristaltic motor activity in the oesophagus, various pharmacological approaches with nitrates, anticholinergics, and calcium antagonists have been used. In the presence of associated lower oesophageal sphincter dysfunction, bouginage or pneumatic dilatation may be indicated. Long oesophagomyotomy should be considered for those patients who fail to respond to these measures.Recent manometric techniques have led to the identification of patients with chest pain or dysphagia who have abnormalities of increased contractile amplitude (‘nutcracker’ oesophagus) or duration. An association with gastrooesophageal reflux or with psychiatric disturbance has been suggested. Treatment directed towards these factors is indicated and may be supplemented by pharmacological intervention, e.g. by calcium antagonists or anticholinergics.

Diffuse pagetoid squamous cell carcinoma in situ of the esophagus

In Western countries, esophageal squamous cell carcinoma is usually advanced at presentation and is rarely diagnosed in situ. The authors studied an in situ squamous cell carcinoma that occupied the entire mucosa of a 9 cm length of esophagus, causing dysphagia for solid food in a woman aged 68 years.

Vascular compression of the esophagus: A manometric and radiologic study

This study was undertaken to determine the prevalence of vascular compression in manometric tracings and to determine whether these findings had any clinical significance. Vascular compression, defined as a localized area of elevated intraesophageal resting pressure >4 mm Hg with superimposed cyclic pressure spikes with a frequency of 60–100/min, was noted in 55 of 241 consecutive tracings. The groups with and without vascular compression were similar with regard to mean age, sex, and prevalence of dysphagia. Radiographs were available for 29 of the 55 and showed compression in 18, but there was no relationship with the manometric findings, except for a trend towards finding a positive esophagogram with amplitudes >16 mm Hg. Eleven tracings showed absent “relaxation” of this elevation of pressure in response to swallows, and five of six available esophagograms showed a corresponding area of compression. We conclude that manometric evidence of vascular compression is common and generally has no clear relationship with esophagographic findings or dysphagia. However, the combined findings of marked increases in pressure and absence of relaxation in response to swallows may indicate evidence for a vascular cause of dysphagia.

On drugs and dilators for achalasia

A decade has passed since the beginning of interest in treating esophageal motor disorders with calcium blockers (1). Despite early enthusiasm, these agents generally have not fulfilled their initial promise (2). Nevertheless, there seemed to be more hope for the successful use of these agents in achalasia, since their effect is greater on the lower esophageal sphincter (LES) than on the esophageal body and achalasia treatment depends on effects on the sphincter. In this issue of the journal, Triadafilopoulos and colleagues report the results of a double-blind crossover study with oral nifedipine versus verapamil versus placebo in the treatment of a small number of patients with achalasia (3). They found that both agents, but particularly nifedipine, diminished LES pressure, but that there was no significant clinical difference between the three treatments. This study confirms the manometric findings of many previous reports, particularly with regard to nifedipine (4-8). Moreover, on a more practical level, the earlier, enthusiastic reports about the use of nifedipine in achalasia have not been substantiated by two double-blind studies, one from our lab (9) and the other being the current study. Should physicians abandon drug treatment for achalasia entirely? I believe the answer is a qualified no. It would make sense to treat only carefully selected patients with medication. Such patients could include those with clinically significant concomitant disease, making dilatations or surgery too risky. My experience is similar to that of others (7) that some patients do relatively well for years. Most, on the other hand, eventually require more definitive therapy. When medical treatment is the choice, it makes sense to choose nifedipine over other medications. Although nitrates can be used, they frequently cause side effects (6), and I have generally avoided them. Nifedipine has a greater effect on the LES than verapamil or diltiazam and is the calcium blocker of choice (1).

Surgical myotomy in patients with high-amplitude peristaltic esophageal contractions

High-amplitude peristaltic esophageal contractions, or the nutcracker esophagus, may be associated with chest pain or dysphagia. Medical treatment for this disorder is sometimes not satisfactory. We report the manometric and clinical effects of myotomy in four patients with high-amplitude peristaltic contractions who underwent surgery because of the severity of their symptoms and recalcitrance to various medical treatments. Manometry 1–5 years after surgery showed a reduction in amplitude, duration, and percent bipeaked waves at 5 and 10 cm above the lower esophageal sphincter. Peristalsis was abolished or decreased in the distal 10 cm of the esophageal body but was not affected more proximally. Lower esophageal sphincter pressure was decreased in all patients. The manometric changes were least marked in one patient, who was the only one who had some chest pain when last seen five years after myotomy. We conclude that in severely symptomatic patients with high-amplitude peristaltic contractions, myotomy results in marked manometric changes and marked clinical improvement. Patients with this disorder and whose chest pain is recalcitrant to extensive medical therapy may be successfully treated by surgical myotomy.