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Current Gastroenterology Reports Jul 2023While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this... (Review)
Review
PURPOSE OF REVIEW
While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.
RECENT FINDINGS
In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
Topics: Humans; Aged; Deglutition Disorders; Esophageal Motility Disorders; Endoscopy, Gastrointestinal; Manometry; Malnutrition; Esophageal Achalasia
PubMed: 37312002
DOI: 10.1007/s11894-023-00876-7 -
Translational Pediatrics Jun 2023Vascular rings, including double aortic arch and right aortic arch with aberrant left subclavian and left ligamentum, are part of a larger group of vascular-related... (Review)
Review
Vascular rings, including double aortic arch and right aortic arch with aberrant left subclavian and left ligamentum, are part of a larger group of vascular-related aerodigestive compression syndromes that also includes innominate artery compression syndrome, dysphagia lusoria, aortic arch anomalies, and aneurysms of either the aorta or pulmonary artery. Additionally, post-surgical airway compression is a distinct entity in itself. The approach to the diagnosis and management of these varied phenomena has been streamlined by the multidisciplinary team at Boston Children's Hospital. Echocardiography, computed tomographic angiography, esophagram, and three-phase dynamic bronchoscopy are routinely performed in these patients in order to produce a comprehensive understanding of the unique anatomic challenges that each patient presents. Adjunctive diagnostic techniques include modified barium swallow, routine preoperative and postoperative screening of the vocal cords, and radiographic identification of the artery of Adamkiewicz. Beyond the vascular reconstruction, which ranges from subclavian-to-carotid transposition to descending aortic translocation, we liberally apply tracheobronchopexy and rotational esophagoplasty to relieve respiratory and esophageal symptoms. Due to the heightened risk for recurrent laryngeal nerve injury, intraoperative recurrent laryngeal nerve monitoring has become routine in these cases. The comprehensive care of these patients requires the coordinated efforts of a large team of dedicated personnel in order to achieve the optimal result.
PubMed: 37427058
DOI: 10.21037/tp-23-39 -
Journal of Indian Association of... 2023Analyze the surgical management strategy and the current effects on Quality of Life of diagnosed Esophageal Achalasia (EA) patients in our department, with an assessment...
PURPOSE
Analyze the surgical management strategy and the current effects on Quality of Life of diagnosed Esophageal Achalasia (EA) patients in our department, with an assessment of the incidence, clinical course, and related disorders.
METHODS
Data was based on a retrospective review of all children who received achalasia treatment at our department between 2008 and 2022. Using the Pediatric Quality of Life Inventory Generic Core (PedsQL) Scales and the Pediatric-QL Gastrointestinal Symptoms Module (GI-PedsQL), we evaluated the long-term effects of this diagnosis on our patients' quality of life.
RESULTS
Esophageal achalasia (EA) was identified in a total of 13 cases (F: 7; M: 6). The mean patient delay was 27.90 months, and the median age was 6.5 years at diagnosis (2 months to 15 years). Regurgitation was the most frequently observed symptom, and the median follow-up was 7.32 (3- 30.7) months. There were descriptions of associations with Allgrove syndrome (n=7) and Down syndrome (n=1). All patients were treated by Open Heller myotomy (OHM) with one patient (n=1) initially treated by pneumatic dilatation (PD). In all 13 laparotomy myotomies, simultaneous fundoplication was performed using the DOR (n=12) and THAL (n=1) techniques. At follow-up, 12 patients had complete symptom relief with 1 patient exhibiting a persistence of symptoms. All 13 patients were prospectively contacted with a median time from latest check-up to date of inclusion of 2.9 (0.3-8.8) years. In comparison to data from a control group of EA patients, the overall PedsQL score of our patients was 72/100 (±17), with higher established scores in physical and emotional functioning but lower scores in social and school settings. On the other hand, when compared to a control group presenting with a gastroesophageal reflux disease (GERD), the GI-PedsQL overall score in our patients was higher with a 76/100 (±14.9), but they scored significantly lower in the dimensions: Foods and drinks limitations, difficulty swallowing, heartburn and vomiting.
DISCUSSION
Our study group's characteristics join most of the published literature with 54% of our patients presenting with Allgrove syndrome but it also joins the much rarer descriptions of Achalasia and Down's syndrome association with a singular case. The clinical course of our diagnosis process mainly consisted of timed esophagram and UGI endoscopy, lacking significantly in HREM evaluations but was efficient enough in guiding the surgical management. Our findings confirm the safety and effectiveness of Open Heller's myotomy with a success rate of 92.3% However, we concede that a laparoscopic approach should be further adopted if no contradiction is found. Moreover, we presented insight on long term QoL of patients posteriori to HM which was in concordance with other global experiences where patients reported dissatisfaction with their health and limited lifestyle. This significant negative impact was prominently present in comparison to healthy control groups as well as patients with inflammatory bowel diseases and compels a much needed discussion on the major chronic repercussions of Esophageal Achalasia in children.
CONCLUSION
Even when managed by interdisciplinary teams of professionals, managing esophageal achalasia in specialized institutions is still a subject of debate. Early pediatric diagnosis is best achieved with routine physiological function tests and HREM. Moreover, more research is required to assess long-term Quality of Life. Standardized lifelong follow-up and qualified resources, both human and technological, are required to improve postoperative outcomes.
PubMed: 38173647
DOI: 10.4103/jiaps.jiaps_67_23 -
Journal of Thoracic Disease Jun 2023Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected...
BACKGROUND
Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected perforation may be transferred to higher levels of care before appropriate work-up and diagnosis confirmation. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow.
METHODS
We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables.
RESULTS
Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included seven states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n=24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n=41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care.
CONCLUSIONS
After transfer a proportion of patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that a recommendation of performing esophagram at the presenting site, when possible, may prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays.
PubMed: 37426131
DOI: 10.21037/jtd-22-1798 -
Cureus Feb 2024Oesophageal perforation (OP) is a life-threatening condition and refers to a tear or disruption in the oesophageal wall. It is considered a medical emergency due to its... (Review)
Review
Oesophageal perforation (OP) is a life-threatening condition and refers to a tear or disruption in the oesophageal wall. It is considered a medical emergency due to its significant implications, often related to its various causes, such as iatrogenic perforation during endoscopy, Boerhaave syndrome, traumatic injury, foreign body ingestion, and tumour perforation. Early interventions, diagnosis, and a thorough physical examination are essential for better clinical outcomes. Diagnostic procedures and imaging techniques, play a crucial role in confirming OP. The diagnostic workup, based on the index of suspicion, may involve barium oesophagram or contrast-enhanced CT. Once diagnosed, classification of severity using the Pittsburgh clinical severity score guides treatment decisions. Management can be non-surgical or surgical and focuses on a multi-disciplinary approach combining conservative, surgical, or endoscopic methods. Surgical control remains crucial, with the approach dependent on the location of the leak. Improved knowledge of this life-threatening condition is important among healthcare professionals. The objective of this review is to provide information about oesophageal perforation and its early detection, management, and multidisciplinary interventions for optimal patient outcomes.
PubMed: 38550481
DOI: 10.7759/cureus.55041 -
Revista Espanola de Enfermedades... Mar 2024We present the case of a patient with smoking, alcoholism, cirrhosis and HIV who was endoscopically diagnosed with esophageal candidiasis due to an episode of dysphagia....
We present the case of a patient with smoking, alcoholism, cirrhosis and HIV who was endoscopically diagnosed with esophageal candidiasis due to an episode of dysphagia. After treatment with antifungals and PPIs, the patient remained asymptomatic for almost 3 years. He presented an event of food impaction that was resolved by an upper endoscopy in which an esophageal stenosis and multiple esophageal pseudodiverticulosis were visualized. The biopsies only showed chronic nonspecific esophagitis. The stenosis was dilated with a balloon and PPIs were continued, with good response. Esophageal intramural pseudodiverticulosis is rare and can lead to motor disorders and strictures. It has a doubtful association with HIV and a clearer relationship with alcoholism, smoking, diabetes, reflux and candidiasis. The endoscopic diagnosis can be difficult so in order to make an accurate diagnosis is necessary an esophagram or CT. Treatment is based on controlling risk factors and dilating stenosis. The prognosis is usually favorable.
PubMed: 38469818
DOI: 10.17235/reed.2024.10282/2024 -
Journal of Gastrointestinal Surgery :... Aug 2023Endoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal organ. With per-oral plication of the esophagus...
BACKGROUND
Endoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal organ. With per-oral plication of the esophagus (POPE), similar plications are used to remodel the dilated and redundant megaesophagus of end-stage achalasia. Redundancies and dilations can also develop in the neoesophagus of a patient with prior esophagectomy. Megaesophagus and a redundant neoesophagus can both lead to debilitating dysphagia, regurgitation, and recurrent aspiration pneumonia. Traditionally, this anatomic problem requires complex revisional or excisional surgery, to which POPE offers an incisionless alternative.
METHODS
This is a dynamic manuscript with video demonstration of POPE, as well as review of five cases performed in 1 year. Data were collected in a prospectively maintained database, and the institutional review board approved retrospective review for this publication. The procedure is performed using a dual-channel upper endoscope fixed with an endoscopic suturing device, with the patient supine under general anesthesia.
RESULTS
POPE was technically completed in all cases with no serious complications, and patients either went home the same day or spent one night for observation. Most patients reported immediate and substantial symptomatic improvement. Objective pre- and post-measures include esophagram and nuclear gastric emptying studies.
CONCLUSION
This article discusses early experience at one institution with POPE, with detailed description of the procedure and technical considerations. An accompanying video reviews two cases, one with megaesophagus and one with a gastric conduit. While this novel procedure has limited and rare indications, it offers a low-morbidity solution to a challenging anatomic problem that traditionally requires invasive surgery.
Topics: Humans; Esophageal Achalasia; Feasibility Studies; Stomach; Gastroplasty; Treatment Outcome
PubMed: 37052876
DOI: 10.1007/s11605-021-05205-9 -
Gastroenterology & Hepatology Feb 2024Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago...
Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago Classification version 4.0, the criteria for this diagnosis have been more stringent. Currently, the criteria include an elevated median integrated relaxation pressure (IRP) in both the supine and upright positions, elevated intrabolus pressure in at least 20% of supine swallows, dysphagia and/or chest pain, as well as an abnormal timed barium esophagram and/or impedance planimetry testing. Additionally, other secondary causes may result in an elevated IRP and must be excluded. The management of conclusive EGJOO is targeted therapy to the lower esophageal sphincter (LES), although treatment is not straightforward. Overall, adjuvant testing and data should be scrutinized for appropriateness of LES disruption. The spectrum of treatment options includes simple monitoring as well as more invasive therapies such as endoscopic dilation and myotomy. This article explores the newest criteria and management options for clinically relevant EGJOO.
PubMed: 38414912
DOI: No ID Found -
Revista Espanola de Enfermedades... Sep 2023A 66-year-old woman presented to our hospital with a long history of solid food dysphagia. Gastroscopy revealed that esophagus was distorted and slightly narrow in the...
A 66-year-old woman presented to our hospital with a long history of solid food dysphagia. Gastroscopy revealed that esophagus was distorted and slightly narrow in the middle section. High-resolution esophageal manometry testing was used to assess the esophageal motor function. We tried to insert the manometric catheter into the patient's stomach, but found that when the patient swallowed, the picture presented an up-down symmetry phenomenon, and the esophageal peristalsis lost its normal slope. Therefore, we believed that the manometer catheter folded back cephalad at her upper esophagus, demonstrating a strange appearance of a curly manometry catheter. Subsequently, a barium esophagram was performed and revealed that there was a stenosis in the middle of the esophagus, and the narrowest of which was about 2cm in diameter. We reviewed the computed tomography and found the aortic arch of the patient was compressing on her esophagus, causing local lumen stenosis.
PubMed: 37732346
DOI: 10.17235/reed.2023.9923/2023