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Achalasia and Candida esophagitis in an immunocompetent patient
S2
Abstracts
AJG – Vol. 96, No. 9, Suppl., 2001
amplitude at 30mm Hg (30) to these relaxation points (30-N; 30-10;30-E), and 3) peak amplitude (P) to the same points (P-N; P-10; P-E). Results: Mean value for each measurement (seconds) shown in the table; p value obtained using independent samples t-test.
Normal Dysphagia p-value
O-N
O–10
O-E
P-N
P-10
P-E
⫺2.25 ⫺2.16 ns
1.93 2.08 ns
3.44 3.35 ns
⫺4.05 ⫺3.95 ns
0.19 0.21 ns
1.53 1.36 ns
No difference between normals and dysphagia patients was found in any measurement.
Conclusions: Premature LES closure does not appear to be a mechanism for dysphagia in patients having otherwise normal manometry. This concept should be abandoned. 4 Does prolonged lower esophageal sphincter relaxation account for heartburn Fawzia Ahmad1, Philip O Katz1, Matthew Gideon1 and Donald O Castell1*. 1Philadelphia, PA, United States. Purpose: Abnormalities in lower esophageal sphincter (LES) relaxation have been associated with dysphagia. The relationship between LES relaxation and heartburn has not been evaluated. Purpose: Determine if there is a relationship between heartburn and prolonged LES relaxation in patients with normal esophageal motility. Methods: 46 normal manometric tracings were divided into 2 groups. Group A ⫽ 23 normal subjects (9F, 14 M; Mean age 39 yr., Range 22–73 yr.). Group B ⫽ 23 aged matched patients with heartburn (13F, 10 M; Mean age 40 yr., Range 23– 84 yr.). Tracings read blinded. Relaxation assessed during three wet swallows. The following parameters were analyzed for each wet swallow (figure). Time (sec) from the start of LES relaxation to the start of distal peristaltic wave (DPW) 3-cm above LES (0-C, C0). Time from the start of DPW to nadir of LES relaxation (C-1, C1), to 10mm Hg above gastric baseline (C-2, C2), to LES resting pressure (C-3, C3). Time from the start of LES relaxation to LES resting pressure (0 –3). Unpaired sample t-test comparing means between Group A and Group B. Results: Table comparing time (seconds) between Group A and Group B (mean ⫹ SE): C0 Group A Group B p value
C1
C2
C3
Total LESR
6.33 ⫾ 0.29 ⫺2.62 ⫾ 0.49 1.90 ⫾ 0.19 3.39 ⫾ 0.14 9.47 ⫾ 0.30 7.30 ⫾ 0.48 ⫺2.82 ⫾ 0.36 2.79 ⫾ 0.25 4.00 ⫾ 0.20 11.51 ⫾ 0.46 ns ns ⬍0.05 ⬍0.05 ⬍0.05
Conclusions: LES relaxation is prolonged in patients with heartburn and normal esophageal body motility. Conclusion: These results support the hypothesis that there is a relationship between heartburn and prolonged LES relaxation in patients with otherwise normal esophageal motility. 5 Utilization of a new less toxic photosensitizer in the treatment of obstructive esophageal tumors by photodynamic therapy (PDT) Mazin F Al-kasspooles, MD1, Hector R Nava, MD1*, Judy L Smith, MD1, Michelle Cooper, RN2, Linda O’Malley, RN2 and Thomas J Dougherty, PhD2. 1Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York; and 2Department of Photodynamic Therapy, Roswell Park Cancer Institute, Buffalo, New York. Purpose: The acceptance of photodynamic therapy (PDT) as a palliative modality for obstructive esophageal cancers by both clinicians and patients has been limited by its cutaneous phototoxicity side effect, which occurs in approximately 20% to 30% of patients and can last up to 4 to 8 weeks. Our institution has recently developed a new photosensitizer, 2-(1-hexyloxy-
ethyl)-2-devinylpyropheophorbide-a (HPPH), that can produce tumor cell damage comparable to Photofrin but without the long-term photosensitivity. Methods: HPPH was utilized in seven patients undergoing endoscopic ablative PDT for obstructive esophageal cancer. Preliminary data were obtained prospectively on safety, complications, objective tumor response, symptomatic relief, and cutaneous phototoxicity, including the use of skin photosensitivity testing. Results: All seven patients had at least some improvement in dysphagia. Five of six (83%) patients that were evaluable after one month had objective tumor responses; two (33%) had complete clinical responses. There was one major complication related to PDT with HPPH (laryngeal edema), which led to emergent tracheostomy. Phototoxicity (sunburn) did not occur in any of the seven patients. Five of seven (71%) patients had no reactions during skin photosensitivity testing (SPT) more than 48 hours after injection of HPPH and none of the patients developed greater than 2⫹ skin reactions (scale: 1– 4) during SPT. Conclusions: Palliative treatment of obstructive esophageal tumors by PDT using HPPH is safe, efficacious, and appears to be associated with a minimal risk of skin phototoxicity. 6 Achalasia and Candida esophagitis in an immunocompetent patient Mouaz H Al-Mallah1 and Moustafa Ibrahim1*. 1Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States. Purpose: Esophageal candidiasis is most common in immunocompromised patients; however, there have been few reports of candida esophagitis in immunocompetent patients. The association between candida esophagitis and achalasia in immunocompetent patients is extremely rare with only two reported cases in the literature, one pregnant patient and a child. Objective: To present a case of Candida esophagitis associated with achalasia in immunocompetent nonpregnant adult. Case Presentation: A 79-year-old African American female with past medical history of hypertension and osteoporosis presented with dysphagia for 10 years and was diagnosed to have achalasia in addition to a large esophageal diverticulum. Four years later, the patient presented with odynophagia and chest pain. Endoscopy revealed hypertonic lower esophageal sphincter and Candidiasis of whole esophagus in addition to large esophageal diverticulum. Esophageal Mucosal brushing grew Candida albicans and Candida glabarata. Patient received intravenous Fluconazole and botulinum toxin was injected to the lower esophageal sphincter. A repeat upper endoscopy revealed no candidiasis, and manometery revealed no peristalsis and the LES tone was low after the botulinum toxin injection. The patient continued to have obstruction due to the diverticulum and advised surgery, but she declined. Conclusions: This is the first report of an association between candida esophagitis and achalasia in a non-immunocompromised adult patient. Only two cases were previously reported, one was in a pregnant lady and the other one was in a child. The nature of this association between candida esophagitis and achalasia is not clear. However, we suspect that the stasis of food in the esophagus perhaps makes an immunocompetent patient more susceptible to candida infection than the average person. 7 A lack of correlation of carditis with gastro-esophageal reflux disease in H. pylori infected subjects Allan H Andrews1, Brian P Mulhall1, Roger K Fincher1, Corinne L Maydonovitch1 and Roy K Wong1*. 1Gastroenterology, Walter Reed Army Medical Center, Washington, DC, United States. Purpose: Carditis is a common finding on endoscopy and is felt to be related to either GERD or H. pylori infection, but controversy exists concerning which is the predominant cause. Carditis may represent the forerunner to intestinal metaplasia and adenocarcinoma of the GE junction.
Abstracts
AJG – Vol. 96, No. 9, Suppl., 2001
amplitude at 30mm Hg (30) to these relaxation points (30-N; 30-10;30-E), and 3) peak amplitude (P) to the same points (P-N; P-10; P-E). Results: Mean value for each measurement (seconds) shown in the table; p value obtained using independent samples t-test.
Normal Dysphagia p-value
O-N
O–10
O-E
P-N
P-10
P-E
⫺2.25 ⫺2.16 ns
1.93 2.08 ns
3.44 3.35 ns
⫺4.05 ⫺3.95 ns
0.19 0.21 ns
1.53 1.36 ns
No difference between normals and dysphagia patients was found in any measurement.
Conclusions: Premature LES closure does not appear to be a mechanism for dysphagia in patients having otherwise normal manometry. This concept should be abandoned. 4 Does prolonged lower esophageal sphincter relaxation account for heartburn Fawzia Ahmad1, Philip O Katz1, Matthew Gideon1 and Donald O Castell1*. 1Philadelphia, PA, United States. Purpose: Abnormalities in lower esophageal sphincter (LES) relaxation have been associated with dysphagia. The relationship between LES relaxation and heartburn has not been evaluated. Purpose: Determine if there is a relationship between heartburn and prolonged LES relaxation in patients with normal esophageal motility. Methods: 46 normal manometric tracings were divided into 2 groups. Group A ⫽ 23 normal subjects (9F, 14 M; Mean age 39 yr., Range 22–73 yr.). Group B ⫽ 23 aged matched patients with heartburn (13F, 10 M; Mean age 40 yr., Range 23– 84 yr.). Tracings read blinded. Relaxation assessed during three wet swallows. The following parameters were analyzed for each wet swallow (figure). Time (sec) from the start of LES relaxation to the start of distal peristaltic wave (DPW) 3-cm above LES (0-C, C0). Time from the start of DPW to nadir of LES relaxation (C-1, C1), to 10mm Hg above gastric baseline (C-2, C2), to LES resting pressure (C-3, C3). Time from the start of LES relaxation to LES resting pressure (0 –3). Unpaired sample t-test comparing means between Group A and Group B. Results: Table comparing time (seconds) between Group A and Group B (mean ⫹ SE): C0 Group A Group B p value
C1
C2
C3
Total LESR
6.33 ⫾ 0.29 ⫺2.62 ⫾ 0.49 1.90 ⫾ 0.19 3.39 ⫾ 0.14 9.47 ⫾ 0.30 7.30 ⫾ 0.48 ⫺2.82 ⫾ 0.36 2.79 ⫾ 0.25 4.00 ⫾ 0.20 11.51 ⫾ 0.46 ns ns ⬍0.05 ⬍0.05 ⬍0.05
Conclusions: LES relaxation is prolonged in patients with heartburn and normal esophageal body motility. Conclusion: These results support the hypothesis that there is a relationship between heartburn and prolonged LES relaxation in patients with otherwise normal esophageal motility. 5 Utilization of a new less toxic photosensitizer in the treatment of obstructive esophageal tumors by photodynamic therapy (PDT) Mazin F Al-kasspooles, MD1, Hector R Nava, MD1*, Judy L Smith, MD1, Michelle Cooper, RN2, Linda O’Malley, RN2 and Thomas J Dougherty, PhD2. 1Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York; and 2Department of Photodynamic Therapy, Roswell Park Cancer Institute, Buffalo, New York. Purpose: The acceptance of photodynamic therapy (PDT) as a palliative modality for obstructive esophageal cancers by both clinicians and patients has been limited by its cutaneous phototoxicity side effect, which occurs in approximately 20% to 30% of patients and can last up to 4 to 8 weeks. Our institution has recently developed a new photosensitizer, 2-(1-hexyloxy-
ethyl)-2-devinylpyropheophorbide-a (HPPH), that can produce tumor cell damage comparable to Photofrin but without the long-term photosensitivity. Methods: HPPH was utilized in seven patients undergoing endoscopic ablative PDT for obstructive esophageal cancer. Preliminary data were obtained prospectively on safety, complications, objective tumor response, symptomatic relief, and cutaneous phototoxicity, including the use of skin photosensitivity testing. Results: All seven patients had at least some improvement in dysphagia. Five of six (83%) patients that were evaluable after one month had objective tumor responses; two (33%) had complete clinical responses. There was one major complication related to PDT with HPPH (laryngeal edema), which led to emergent tracheostomy. Phototoxicity (sunburn) did not occur in any of the seven patients. Five of seven (71%) patients had no reactions during skin photosensitivity testing (SPT) more than 48 hours after injection of HPPH and none of the patients developed greater than 2⫹ skin reactions (scale: 1– 4) during SPT. Conclusions: Palliative treatment of obstructive esophageal tumors by PDT using HPPH is safe, efficacious, and appears to be associated with a minimal risk of skin phototoxicity. 6 Achalasia and Candida esophagitis in an immunocompetent patient Mouaz H Al-Mallah1 and Moustafa Ibrahim1*. 1Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States. Purpose: Esophageal candidiasis is most common in immunocompromised patients; however, there have been few reports of candida esophagitis in immunocompetent patients. The association between candida esophagitis and achalasia in immunocompetent patients is extremely rare with only two reported cases in the literature, one pregnant patient and a child. Objective: To present a case of Candida esophagitis associated with achalasia in immunocompetent nonpregnant adult. Case Presentation: A 79-year-old African American female with past medical history of hypertension and osteoporosis presented with dysphagia for 10 years and was diagnosed to have achalasia in addition to a large esophageal diverticulum. Four years later, the patient presented with odynophagia and chest pain. Endoscopy revealed hypertonic lower esophageal sphincter and Candidiasis of whole esophagus in addition to large esophageal diverticulum. Esophageal Mucosal brushing grew Candida albicans and Candida glabarata. Patient received intravenous Fluconazole and botulinum toxin was injected to the lower esophageal sphincter. A repeat upper endoscopy revealed no candidiasis, and manometery revealed no peristalsis and the LES tone was low after the botulinum toxin injection. The patient continued to have obstruction due to the diverticulum and advised surgery, but she declined. Conclusions: This is the first report of an association between candida esophagitis and achalasia in a non-immunocompromised adult patient. Only two cases were previously reported, one was in a pregnant lady and the other one was in a child. The nature of this association between candida esophagitis and achalasia is not clear. However, we suspect that the stasis of food in the esophagus perhaps makes an immunocompetent patient more susceptible to candida infection than the average person. 7 A lack of correlation of carditis with gastro-esophageal reflux disease in H. pylori infected subjects Allan H Andrews1, Brian P Mulhall1, Roger K Fincher1, Corinne L Maydonovitch1 and Roy K Wong1*. 1Gastroenterology, Walter Reed Army Medical Center, Washington, DC, United States. Purpose: Carditis is a common finding on endoscopy and is felt to be related to either GERD or H. pylori infection, but controversy exists concerning which is the predominant cause. Carditis may represent the forerunner to intestinal metaplasia and adenocarcinoma of the GE junction.