Background:Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes most

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Prospective Single Center Study

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL) The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI) Only statements with an approval rate >80% were accepted in the guidelines Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease

The 2018 ISDE achalasia guidelines

Background: Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium.

Aims: We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates.

Methods: Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence.

Results: Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months).

Conclusions: (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.

https://gut.bmj.com/content/gutjnl/50/6/765.full.pdf

Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment.

BACKGROUND\nEndoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques.\n\n\nMETHODS\nIn this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival.\n\n\nRESULTS\nActive bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections.\n\n\nCONCLUSIONS\nPatients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophagal varices

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time.

OBJECTIVE To identify hematological, biochemical and ultrasonographic predictors of esophageal varices in patients of cirrhosis. DESIGN Cross-sectional, analytical study. PLACE AND DURATION OF STUDY Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, from September 2003 to March 2004. PATIENTS AND METHODS One hundred and one patients with established cirrhosis and no history of variceal bleed underwent physical examination, hematological, biochemical tests and abdominal ultrasound examination. Esophagogastroduodenoscopy (EGD) was carried out in all patients. Presence of varices on EGD was correlated with hematological, biochemical and ultrasonographic variables by regression analysis. RESULTS Esophageal varices were seen in 65 patients while 36 patients had no varices. High grade varices were seen in 15 patients and 50 patients had low grade varices. Serum albumin less than 2.95 g/dl, platelet count less than 88 x 103/muL and portal vein diameter more than 11 mm were associated with presence of varices. High grade varices were predicted by serum albumin 11 mm are more likely to have high grade varices. These patients are candidates for surveillance endoscopy.

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

Objective To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy. Study design Randomized, placebo-controlled trial. Place and duration of study Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005. Methodology Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate (20 g/d) or placebo, both dissolved in 250 mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined. Results Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died. Conclusion L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy.

/pdf/l-ornithine-l-aspartate-infusion-efficacy-in-hepatic-1shcyyu8ou.pdf

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy.

Objective To determine the efficacy of reagent strip for bedside diagnosis of spontaneous bacterial peritonitis (SBP). Design Cross-sectional analytical study. Place and duration of study Shaikh Zayed Postgraduate Medical Institute from November 2003 to August 2004. Patients and methods Patients with cirrhosis and ascites underwent diagnostic paracentesis. Fluid was checked for leukocyte esterase released by PMN by using Combur 10 urine strip and graded for color change from 0-3. Fluid was also analyzed by cytology for PMN count. Results of both methods were compared to determine sensitivity, specificity and accuracy of strip for diagnosis of SBP. Results Of 214 paracentesis performed, SBP was diagnosed in 38 patients whereas 176 were negative for infection. Strip test was 97.7% sensitive and 89.4% specific with positive predictive value of 90%, negative predictive value of 97.7% and accuracy of 96.2%, when reagent strip grade 3 was considered as positive for diagnosis. Conclusion Reagent strip is a quick bedside test, highly sensitive and specific for the diagnosis of SBP, based on polymorphonuclear count in ascitic fluid, to initiate early treatment, thus improving patient's outcome.

Bedside diagnosis of spontaneous bacterial peritonitis using reagent strips.

Objective: To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. Study Design: A prospective randomized trial. Place and Duration of Study: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. Methodology: One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. Results: Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant. Conclusion: There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

/pdf/propranolol-isosorbide-mononitrate-and-endoscopic-band-227o21mpw3.pdf

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

Anwaar A Khan

Papers

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time.

Non-endoscopic prediction of presence of esophageal varices in cirrhosis.

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy.

Bedside diagnosis of spontaneous bacterial peritonitis using reagent strips.

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.