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Su1885 Radiographic and Symptomatic Characteristics Among the 3 Subtypes of Esophageal Achalasia Defined by Chicago Classification With High-Resolution Manometry
AGA Abstracts
chose acid, 8 sweet, 3 bitter. Subjective improvement in swallowing was reported by 10 patients, 6/8 on sweet thickener, 2/9 on acid, and 2/3 on bitter thickener. Objective improvement of the SDQ score was reported by 13/20, patients 5/9 on acid thickener, 7/8 on sweet, and 1/3 on bitter. Score for cough during swallowing of liquid was rated 2.2±1.0 on usual diet and 1.8±1.0 (p ,0.03) after 6 weeks on preferred taste thickener. There was not significant body weight variation during the study period: 20% increased .1 Kg, 65% remained stable ,and 15 decreased .1 kg. Conclusions. Taste can affect swallowing function in ALS patients, being sweet and acid the most preferred and effective flavors. Flavoring liquid thickener with individualized selected taste can improve the swallowing act in ALS patients. 1) Logemann JA et al. J Speech Hear Res 1995;38:556-63 2) Cohen JT, Manor Y. The laryngoscope 2011 Su1883
Su1885
Occurrence of Esophageal Symptoms After Radiation and/or Chemotherapy in Patients With Lung Cancer Compared to Patients With Breast Cancer or Lymphoma Helen M. Shields, Justin W. Li, Helen H. Wang, Stephen R. Pelletier, Rachel Freedman, Harvey Mamon, Andrea K. Ng, Arnold Freedman, Steven Come, David Avigan, Mark Huberman, Abram Recht
Radiographic and Symptomatic Characteristics Among the 3 Subtypes of Esophageal Achalasia Defined by Chicago Classification With High-Resolution Manometry Hiroko Hosaka, Akiyo Kawada, Shiko Kuribayashi, Yasuyuki Shimoyama, Masaki Maeda, Atsuto Nagoshi, Hiroaki Zai, Osamu Kawamura, Motoyasu Kusano Background and Aim: A new manometric classification of esophageal achalasia (Chicago classification: CC) using high resolution manometry (HRM) has recently been proposed. However, the pathophysiology of esophageal dysmotility, which causes these manometric differences, is still unclear. The aims of this study were to compare radiographic and symptomatic characteristics among the subtypes of achalasia in order to verify the CC in Japanese patients. Materials and methods: HRM was performed with ManoScanZ (HRM system with impedance monitoring, USA) between 2009 and 2012 in our university hospital on 281 patients with dysphagia and/or chest pain after excluding upper GI organic diseases by endoscopy. Forty newly diagnosed achalasia patients were enrolled in the study. The patients were categorized into 3 subtypes according to CC: Type I, no esophageal pressurization in 8 of 10 swallows; type II, pan-esophageal compression .30mmHg; and type III with spasm. Symptoms were analyzed by a structured self-reported questionnaire, which focused on dysphagia symptoms, especially the place (throat, retrosternum, epigastrium) and the timing (immediate, within 10 seconds, after 10 seconds) after a swallow. Esophagograms with video-fluoroscopy were taken with 100ml of barium to evaluate the diameter of the distal esophagus and to determine the radiographic findings, including "irregular contractions of the esophagus (ICE)", "retrograde flow of barium (RFB)", and "liquid trapped in the esophagus (LTE)". HRM variables, detailed symptoms and radiographic findings were compared among the subtypes. Results: The enrolled patients were classified into type I (n= 17), II (n=20), and III (n=3), respectively. The radiographic predominant achalasia pattern of type I was characterized by severe dilatation (mean diameter: 5.8±1.9cm), common LTE (100%), less RFB (8%), and less ICE (25%). Type II had more RFB (61%) and ICE (72%). Type III was characterized by the smallest diameter (mean diameter: 3.2±0.7cm), common RFB (100%) and no LTE (0%). By HRM, the contractile amplitude of the distal esophagus was the significantly (ANOVA, p,0.01) lowest in type I (16.1 mm Hg) and the highest in type III (92.4 mm Hg), and intermediate in type II (29.7 mmHg). Symptomatically, type I patients had less (Fisher's exact test, p=0.073) chest pain (18%) than did type II (50%) and type III (66%). Type II patients often described dysphagia at "throat" and "immediate" according to the questionnaire. Conclusions: Manometric and radiographic findings were distinctive according to the subgroups of CC, probably reflecting pathophysiology and clinical significance of the patients with achalasia. CC seems to be suitable for clinical application in achalasia.
Background: Esophageal symptoms are common complaints of patients during radiation and chemotherapy, but few data exist on how often these persist following treatment. Aims: 1. To describe how often patients treated with radiation and/or chemotherapy for breast cancer, lung cancer, or lymphoma have esophageal symptoms before and during treatment and at 10-14 months after completion of cancer therapy. 2. To record the acid suppression treatments used in patients with esophageal symptoms. Methods: Eligible patients were 18 years and older, underwent radiation therapy and/or chemotherapy for non-metastatic breast cancer, lung cancer, or lymphoma (Hodgkin and non-Hodgkin) between January 2005 and December 2010 at Beth Israel Deaconess Medical Center and Dana-Farber Cancer Institute/ Brigham and Women's Hospital and had available electronic medical records allowing assessment of esophageal symptoms by a trained reviewer. Patients were screened for heartburn, dysphagia and odynophagia at their pre-treatment baseline, during and post-treatment. We recorded acid suppression medications given prior to, during and post-treatment. Statistical significance was tested using the Chi-square statistic. Results: The final study populations included 86 breast cancer, 118 lung cancer, and 129 lymphoma patients. Patients who had either radiation or chemotherapy alone for any of the three cancers had no significant change in the incidence of esophageal symptoms during or 10-14 months post-treatment, compared to pre-treatment. Patients who received both chemotherapy and radiation that did not involve the mediastinum also did not show a significant increase in symptoms. However, among patients who received chemotherapy combined with radiation that involved the mediastinum, the rate of dysphagia increased from 5% pre- to 28% post-treatment (p ,.001). Odynophagia increased from 0% pre- to 11% post-treatment (p ,.001). Lung cancer patients were the ones most likely to receive radiation to the mediastinum, whether sequentially or concurrently with chemotherapy, and they had significantly more esophageal symptoms than lymphoma and breast cancer patients (p ,.05). Use of proton pump inhibitors or acid suppressing medications was significantly higher in lung cancer patients compared to breast or lymphoma patients both during and post-treatment (p= .002). Conclusions: Esophageal symptoms were significantly more common during and after treatment when patients received both chemotherapy and radiation that involved the mediastinum. Although our current study does not answer the question of whether proton pump inhibitor therapy was effective in diminishing esophageal symptoms, we speculate that prophylactic use of proton pump inhibitors may be warranted in patients who undergo such treatment, particularly for lung cancer.
Su1886 Su1884
Spastic and Hypertensive Esophageal Motility Disorders: Is Botulinum Toxin Useful? Sophie Marjoux, Sabine Roman, Carole Paillet, Vincent Lepilliez, Rodica Gincul, Thierry Ponchon, Francois Mion
Long- Term Impact of BoTox Injection in Patients With Spastic Esophageal Motility Disorders Genaro Vazquez-Elizondo, Kenneth R. DeVault, Sami R. Achem
Background: Esophageal motor disorders such as spastic or hypertensive peristaltic disorders are a rare cause of dysphagia and chest pain. Their treatment is usually difficult. Endoscopic botulinum toxin injection has been proposed to treat diffuse esophageal spasm (1). Our aim was to evaluate the tolerance and the efficacy of this treatment in a retrospective monocentric study. Patients and Methods: We retrospectively reviewed the charts of all patients treated with endoscopic botulinum toxin injection in the esophagus. Esophageal motility disorders were diagnosed according to the Chicago Classification for high resolution manometry with esophageal pressure topography (EPT) (2). EPT recordings were systematically re-analyzed and a patient's phone survey was conducted. Results: From 2008 to 2012, 17 patients (7 men, mean age 57 years, range 28-87) were treated with one endoscopic session of botulinum toxin injection (100 IU in the cardia and/or in the distal third of the esophagus). All patients were refractory to previous medical treatment. The EPT diagnoses were distributed as follow: type III achalasia (n=9, 53%), Jackhammer esophagus (n=5, 29%), distal esophageal spasm (DES) (n=1, 6%), Nutcracker esophagus (n=1, 6%) and prominent post-deglutitive lower esophageal sphincter contraction (n=1, 6%). The main pre-operative complaints were dysphagia (100%) and chest pain (90%). The mean weight loss was 4 kg (range 0-15). No serious adverse effects occurred during and after botulinum toxin injection. Chest pain was reported in 9 cases (53%) after the procedure and lasted for 1 to 7 days (mean 3 days). Morphine was required in 2 patients to relieve pain. Clinical efficacy (decrease of dysphagia and/or chest pain) is detailed in the Table. Seven patients (all the 5 Jackhammer esophagus (100%) and 2 cases of achalasia (50%)) were symptomfree within a mean follow-up of 5 months (range 2-11). Four patients relapsed 2 to 9 months after botulinum toxin injection (mean 4 months); 2 of them had achalasia, 1 DES and 1 prominent post-deglutitive lower esophageal sphincter contraction. Post-treatment EPT recordings were available in 7 patients (4 achalasia, 2 Jackhammer, 1 DES). Only the 2 Jackhammer esophagus turned into normal esophageal motility after botulinum toxin injection. Conclusion: Endoscopic esophageal injection of botulinum toxin seems effective for esophageal motility disorders. The main adverse event was chest pain in half of cases. Clinical
Treatment of esophageal spastic disorders remains challenging. Open label studies have reported short- term beneficial results following botulinum toxin (Botox) injection of the esophagus. There is limited information regarding long-term outcome following this approach. AIMS: Describe the long term (2 years and beyond) clinical outcome of patients receiving Botox injection of the esophagus for the treatment of non-achalasia esophageal motility disorders. METHODS: We searched the electronic pharmacy records of all consecutive patients who received Botox injection at our institution from 2001-2011. All consecutive subjects who were injected with Botox for esophageal symptoms related to non-achalasia spastic esophageal motility disorders were included in the study. The clinical records of these patients were reviewed for verification of demographics, symptoms, time, location and dose of Botox injection, clinical response, follow up time and complications. Clinical response was evaluated with an absolute scale as: improved/better (no need for additional therapy), same/no response or worse (requires additional therapy for symptom improvement). RESULTS: During the study period we identified 49 patients who had Botox injection who met inclusion criteria. Mean age 70 years (47-91), male n=26 (53%), dysphagia n=43 (88%), chest pain n=22 (45%), distal esophageal spasm 27 (55%), nutcracker esophagus 15 (31%), hypertensive LES 4 (8%), incompletely relaxing LES 3 (6%). A total of 86 Botox injections were performed and 17 patients (35%) received more than 1 injection (mean 3.3 ± 2.3 [211]). The most frequent site for injection was the gastroesophageal junction n = 63/86 (73%) and the most frequent dose used was 100 units (n = 80/86 (93%). Follow up was available in n = 38 (78%), mean follow-up 28.5 ± 34.9 months [1 - 159]). The mean time of symptom duration improvement was 19.9 ± 17.2 months [1 - 69.4]. No complications or major side effects were noted during the study. The table summarizes the effects of Botox injection during a 60 month follow-up. CONCLUSIONS: Botox injection of the esophagus for patients with spastic esophageal motility disorders provides an effective and safe therapeutic approach with reasonable sustained effect on symptom improvement.
AGA Abstracts
S-500
chose acid, 8 sweet, 3 bitter. Subjective improvement in swallowing was reported by 10 patients, 6/8 on sweet thickener, 2/9 on acid, and 2/3 on bitter thickener. Objective improvement of the SDQ score was reported by 13/20, patients 5/9 on acid thickener, 7/8 on sweet, and 1/3 on bitter. Score for cough during swallowing of liquid was rated 2.2±1.0 on usual diet and 1.8±1.0 (p ,0.03) after 6 weeks on preferred taste thickener. There was not significant body weight variation during the study period: 20% increased .1 Kg, 65% remained stable ,and 15 decreased .1 kg. Conclusions. Taste can affect swallowing function in ALS patients, being sweet and acid the most preferred and effective flavors. Flavoring liquid thickener with individualized selected taste can improve the swallowing act in ALS patients. 1) Logemann JA et al. J Speech Hear Res 1995;38:556-63 2) Cohen JT, Manor Y. The laryngoscope 2011 Su1883
Su1885
Occurrence of Esophageal Symptoms After Radiation and/or Chemotherapy in Patients With Lung Cancer Compared to Patients With Breast Cancer or Lymphoma Helen M. Shields, Justin W. Li, Helen H. Wang, Stephen R. Pelletier, Rachel Freedman, Harvey Mamon, Andrea K. Ng, Arnold Freedman, Steven Come, David Avigan, Mark Huberman, Abram Recht
Radiographic and Symptomatic Characteristics Among the 3 Subtypes of Esophageal Achalasia Defined by Chicago Classification With High-Resolution Manometry Hiroko Hosaka, Akiyo Kawada, Shiko Kuribayashi, Yasuyuki Shimoyama, Masaki Maeda, Atsuto Nagoshi, Hiroaki Zai, Osamu Kawamura, Motoyasu Kusano Background and Aim: A new manometric classification of esophageal achalasia (Chicago classification: CC) using high resolution manometry (HRM) has recently been proposed. However, the pathophysiology of esophageal dysmotility, which causes these manometric differences, is still unclear. The aims of this study were to compare radiographic and symptomatic characteristics among the subtypes of achalasia in order to verify the CC in Japanese patients. Materials and methods: HRM was performed with ManoScanZ (HRM system with impedance monitoring, USA) between 2009 and 2012 in our university hospital on 281 patients with dysphagia and/or chest pain after excluding upper GI organic diseases by endoscopy. Forty newly diagnosed achalasia patients were enrolled in the study. The patients were categorized into 3 subtypes according to CC: Type I, no esophageal pressurization in 8 of 10 swallows; type II, pan-esophageal compression .30mmHg; and type III with spasm. Symptoms were analyzed by a structured self-reported questionnaire, which focused on dysphagia symptoms, especially the place (throat, retrosternum, epigastrium) and the timing (immediate, within 10 seconds, after 10 seconds) after a swallow. Esophagograms with video-fluoroscopy were taken with 100ml of barium to evaluate the diameter of the distal esophagus and to determine the radiographic findings, including "irregular contractions of the esophagus (ICE)", "retrograde flow of barium (RFB)", and "liquid trapped in the esophagus (LTE)". HRM variables, detailed symptoms and radiographic findings were compared among the subtypes. Results: The enrolled patients were classified into type I (n= 17), II (n=20), and III (n=3), respectively. The radiographic predominant achalasia pattern of type I was characterized by severe dilatation (mean diameter: 5.8±1.9cm), common LTE (100%), less RFB (8%), and less ICE (25%). Type II had more RFB (61%) and ICE (72%). Type III was characterized by the smallest diameter (mean diameter: 3.2±0.7cm), common RFB (100%) and no LTE (0%). By HRM, the contractile amplitude of the distal esophagus was the significantly (ANOVA, p,0.01) lowest in type I (16.1 mm Hg) and the highest in type III (92.4 mm Hg), and intermediate in type II (29.7 mmHg). Symptomatically, type I patients had less (Fisher's exact test, p=0.073) chest pain (18%) than did type II (50%) and type III (66%). Type II patients often described dysphagia at "throat" and "immediate" according to the questionnaire. Conclusions: Manometric and radiographic findings were distinctive according to the subgroups of CC, probably reflecting pathophysiology and clinical significance of the patients with achalasia. CC seems to be suitable for clinical application in achalasia.
Background: Esophageal symptoms are common complaints of patients during radiation and chemotherapy, but few data exist on how often these persist following treatment. Aims: 1. To describe how often patients treated with radiation and/or chemotherapy for breast cancer, lung cancer, or lymphoma have esophageal symptoms before and during treatment and at 10-14 months after completion of cancer therapy. 2. To record the acid suppression treatments used in patients with esophageal symptoms. Methods: Eligible patients were 18 years and older, underwent radiation therapy and/or chemotherapy for non-metastatic breast cancer, lung cancer, or lymphoma (Hodgkin and non-Hodgkin) between January 2005 and December 2010 at Beth Israel Deaconess Medical Center and Dana-Farber Cancer Institute/ Brigham and Women's Hospital and had available electronic medical records allowing assessment of esophageal symptoms by a trained reviewer. Patients were screened for heartburn, dysphagia and odynophagia at their pre-treatment baseline, during and post-treatment. We recorded acid suppression medications given prior to, during and post-treatment. Statistical significance was tested using the Chi-square statistic. Results: The final study populations included 86 breast cancer, 118 lung cancer, and 129 lymphoma patients. Patients who had either radiation or chemotherapy alone for any of the three cancers had no significant change in the incidence of esophageal symptoms during or 10-14 months post-treatment, compared to pre-treatment. Patients who received both chemotherapy and radiation that did not involve the mediastinum also did not show a significant increase in symptoms. However, among patients who received chemotherapy combined with radiation that involved the mediastinum, the rate of dysphagia increased from 5% pre- to 28% post-treatment (p ,.001). Odynophagia increased from 0% pre- to 11% post-treatment (p ,.001). Lung cancer patients were the ones most likely to receive radiation to the mediastinum, whether sequentially or concurrently with chemotherapy, and they had significantly more esophageal symptoms than lymphoma and breast cancer patients (p ,.05). Use of proton pump inhibitors or acid suppressing medications was significantly higher in lung cancer patients compared to breast or lymphoma patients both during and post-treatment (p= .002). Conclusions: Esophageal symptoms were significantly more common during and after treatment when patients received both chemotherapy and radiation that involved the mediastinum. Although our current study does not answer the question of whether proton pump inhibitor therapy was effective in diminishing esophageal symptoms, we speculate that prophylactic use of proton pump inhibitors may be warranted in patients who undergo such treatment, particularly for lung cancer.
Su1886 Su1884
Spastic and Hypertensive Esophageal Motility Disorders: Is Botulinum Toxin Useful? Sophie Marjoux, Sabine Roman, Carole Paillet, Vincent Lepilliez, Rodica Gincul, Thierry Ponchon, Francois Mion
Long- Term Impact of BoTox Injection in Patients With Spastic Esophageal Motility Disorders Genaro Vazquez-Elizondo, Kenneth R. DeVault, Sami R. Achem
Background: Esophageal motor disorders such as spastic or hypertensive peristaltic disorders are a rare cause of dysphagia and chest pain. Their treatment is usually difficult. Endoscopic botulinum toxin injection has been proposed to treat diffuse esophageal spasm (1). Our aim was to evaluate the tolerance and the efficacy of this treatment in a retrospective monocentric study. Patients and Methods: We retrospectively reviewed the charts of all patients treated with endoscopic botulinum toxin injection in the esophagus. Esophageal motility disorders were diagnosed according to the Chicago Classification for high resolution manometry with esophageal pressure topography (EPT) (2). EPT recordings were systematically re-analyzed and a patient's phone survey was conducted. Results: From 2008 to 2012, 17 patients (7 men, mean age 57 years, range 28-87) were treated with one endoscopic session of botulinum toxin injection (100 IU in the cardia and/or in the distal third of the esophagus). All patients were refractory to previous medical treatment. The EPT diagnoses were distributed as follow: type III achalasia (n=9, 53%), Jackhammer esophagus (n=5, 29%), distal esophageal spasm (DES) (n=1, 6%), Nutcracker esophagus (n=1, 6%) and prominent post-deglutitive lower esophageal sphincter contraction (n=1, 6%). The main pre-operative complaints were dysphagia (100%) and chest pain (90%). The mean weight loss was 4 kg (range 0-15). No serious adverse effects occurred during and after botulinum toxin injection. Chest pain was reported in 9 cases (53%) after the procedure and lasted for 1 to 7 days (mean 3 days). Morphine was required in 2 patients to relieve pain. Clinical efficacy (decrease of dysphagia and/or chest pain) is detailed in the Table. Seven patients (all the 5 Jackhammer esophagus (100%) and 2 cases of achalasia (50%)) were symptomfree within a mean follow-up of 5 months (range 2-11). Four patients relapsed 2 to 9 months after botulinum toxin injection (mean 4 months); 2 of them had achalasia, 1 DES and 1 prominent post-deglutitive lower esophageal sphincter contraction. Post-treatment EPT recordings were available in 7 patients (4 achalasia, 2 Jackhammer, 1 DES). Only the 2 Jackhammer esophagus turned into normal esophageal motility after botulinum toxin injection. Conclusion: Endoscopic esophageal injection of botulinum toxin seems effective for esophageal motility disorders. The main adverse event was chest pain in half of cases. Clinical
Treatment of esophageal spastic disorders remains challenging. Open label studies have reported short- term beneficial results following botulinum toxin (Botox) injection of the esophagus. There is limited information regarding long-term outcome following this approach. AIMS: Describe the long term (2 years and beyond) clinical outcome of patients receiving Botox injection of the esophagus for the treatment of non-achalasia esophageal motility disorders. METHODS: We searched the electronic pharmacy records of all consecutive patients who received Botox injection at our institution from 2001-2011. All consecutive subjects who were injected with Botox for esophageal symptoms related to non-achalasia spastic esophageal motility disorders were included in the study. The clinical records of these patients were reviewed for verification of demographics, symptoms, time, location and dose of Botox injection, clinical response, follow up time and complications. Clinical response was evaluated with an absolute scale as: improved/better (no need for additional therapy), same/no response or worse (requires additional therapy for symptom improvement). RESULTS: During the study period we identified 49 patients who had Botox injection who met inclusion criteria. Mean age 70 years (47-91), male n=26 (53%), dysphagia n=43 (88%), chest pain n=22 (45%), distal esophageal spasm 27 (55%), nutcracker esophagus 15 (31%), hypertensive LES 4 (8%), incompletely relaxing LES 3 (6%). A total of 86 Botox injections were performed and 17 patients (35%) received more than 1 injection (mean 3.3 ± 2.3 [211]). The most frequent site for injection was the gastroesophageal junction n = 63/86 (73%) and the most frequent dose used was 100 units (n = 80/86 (93%). Follow up was available in n = 38 (78%), mean follow-up 28.5 ± 34.9 months [1 - 159]). The mean time of symptom duration improvement was 19.9 ± 17.2 months [1 - 69.4]. No complications or major side effects were noted during the study. The table summarizes the effects of Botox injection during a 60 month follow-up. CONCLUSIONS: Botox injection of the esophagus for patients with spastic esophageal motility disorders provides an effective and safe therapeutic approach with reasonable sustained effect on symptom improvement.
AGA Abstracts
S-500