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L’achalasie idiopathique est une affection bien définie sur des critères cliniques radiologiques et manométriques, même si des formes atypiques ou intermédiaires avec la maladie des spasmes diffus, sont décrites. L’étiologie est inconnue mais des progrès dans la compréhension des mécanismes physiopathologiques — atteinte de la voie inhibitrice NO médiée — et dans la physiopathologie ont été faits. Une ganglionnite avec infiltrat lymphocytaire est peut-être liée à des virus du groupe herpès. La mise en évidence d’un facteur sérique altérant le fonctionnement des neurones myentériques humains par l’équipe de Nantes laisse entrevoir la possibilité d’un traitement étiologique s’adressant aux mécanismes dysimmunitaires. Dans l’attente d’une cible étiologique, le traitement vise à supprimer l’obstacle fonctionnel distal. Les myorelaxants et particulièrement la nifédipine doivent être proposés dans les formes débutantes et chez les sujets âgés. La toxine botulique est décevante avec le recul. Elle est utile dans l’achalasie vigoureuse, chez les sujets âgés. La dilatation pneumatique et la myotomie de Heller cœlioscopique sont des traitements qui visent à un résultat définitif. Les variantes de procédure tant endoscopiques que chirurgicales rendent les comparaisons difficiles. Une étude européenne comparant dilatation pneumatique progressive et myotomie cœlioscopique avec valve de Dorr est en cours. Les résultats à long terme des deux thérapeutiques sont moins bons qu’espérés et justifient la surveillance régulière des patients pour traiter l’œsophagite de stase, le reflux, l’endobrachy-œsophage et le risque de carcinome. Idiopathic achalasia is an affliction with well defined radiological and manometric clinical criteria, although atypical or intermediary forms with diffuse oesophageal spasm have been described. The etiology is unknown but progress has been made regarding the understanding of the physiopathological mechanisms — involvement of the NO mediated inhibitory pathway — and physiopathology. Ganglionitis with lymphocytic infiltration is perhaps related to a herpes group virus. The observation of a serum factor altering the functioning of human myenteric neurons by the Nantes team raises the possibility of an etiological treatment aimed at dysimmune mechanisms. Until an etiological target is found, treatment consists of removing the distal functional obstacle. Myorelaxants, and particularly nifedipine, should be proposed in the early forms and in elderly subjects. Botulinum toxin is disappointing in retrospect. It is useful in vigorous achalasia, in elderly subjects. Pneumatic dilation and coelioscopic Heller myotomy are treatments that aim at a definitive result. The endoscopic as well as surgical procedural variants render comparisons difficult. A European study comparing progressive pneumatic dilation to coelioscopic myotomy with Dorr valve is underway. The long term results of these two therapies are less than expected and justify regular monitoring of patients for treatment of stasis oesophagitis, reflux, endobrachyoesophagus and the risk of carcinoma. [ABSTRACT FROM AUTHOR]

Les troubles moteurs primitifs de l’œsophage regroupent des troubles moteurs d’étiologie indéterminée affectant le corps de l’œsophage et/ou le sphincter inférieur de l’œsophage. Les symptômes habituels sont dominés par la dysphagie et les douleurs pseudo angineuses. Le diagnostic repose encore aujourd’hui sur les anomalies manométriques. Mais les signes manométriques sont souvent inconstants et les définitions manométriques non consensuelles. Grâce aux progrès sur la connaissance de la pathogénie, d’autres explorations peuvent aider au diagnostic telles que la manométrie holter ou l’écho endoscopie. La maladie des spasmes diffus, l’œsophage casse-noisettes (péristaltisme douloureux), l’hypertonie du sphincter inférieur de l’œsophage et la motricité inefficace œsophagienne sont présentés dans cette revue des troubles moteurs primitifs de l’œsophage. Un chapitre est particulièrement consacré à la pathogénie des douleurs œsophagiennes en abordant les avancées récentes dans la connaissance de la pathogénie, du diagnostic et des traitements. L’efficacité des traitements médicamenteux est souvent décevante avec des problèmes de tolérance. La prise en charge d’un reflux gastro-œsophagien ou des troubles psychiatriques associés peut améliorer les résultats, notamment en cas de troubles moteurs non spécifiques. Les résultats des traitements endoscopiques (bougienage, dilatation pneumatique, toxine botulique) sont présentés, ainsi que ceux de la myotomie chirurgicale qui doit être réservée aux troubles les plus sévères. Primary esophageal motility disorders consist of a complex group of motor disturbances, affecting the contractions and peristalsis of the esophageal body and/or the lower esophageal sphincter function. They can cause a variety of esophageal complaints, mostly dysphagia and chest pain. In the absence of an obvious etiology their classification is based on the manometric abnormalities. However, in the last decade progress was made in the understanding of the pathologic mechanisms involved. The diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter and the ineffective esophageal motility are presented. A special chapter is reserved to the chest pain of esophageal origin, and the recent advances in its pathogenesis, diagnosis and treatment are discussed. The pharmacological therapies of the primary esophageal motility disorders have limited efficacy. The results of the main endoscopic treatments (bougies, pneumatic dilation and botulinum toxin injection) are presented and their results are compared to surgery. More efficacious medical therapies for the nonspecific motility disorders are directed at associated reflux disease or psychiatric disturbances. [ABSTRACT FROM AUTHOR]

A prospective study is undertaken in order to demonstrate the ability of scintigraphy with a non compartmental analysis to quantitate the duodeno-gastric reflux. 24 patients have been examined, sitting in front of a gamma camera: 12 with an endoscopically proved reflux and 12 normal subjects or volunteers. About 15 min after an injection of 148 to 222 MBq 99Tcm-IDA they were given a meal labelled with 37 MBq 113Inm-DTPA. Images were recorded for 2 h. Equal size gastric and duodenal ROIs were selected over the duodenum and stomach, avoiding overlap with neighbouring organs. The reflux index based upon the occupancy principle is calculated from the gastric and duodenal curves. It is the ratio between the gastric and duodenal ROI IDA fluxes. The value of the reflux index is 3±1.8 in normal subjects and 45±33 in pathological cases.

An original method is described for graphic display of sounds araising from the cardia during the swallowing of saliva or water. Two dynamic microphones were placed on the skin of epigastric xyphoïd area and simultaneously on the latero-cervical position. The following conditions must be filled: position of the subject (upright or lying), correct application of microphone with pressure (2 kPa), specially for the xyphoïd situation. For graphic restitutions from magnetic signal, a time-recording paper was used, on line or off line, with an analogical device including Butterworth band active filter (optimal frequency range 0.8-1.2 kHz), amplifier and integrator (t = 2 s). Occurence of typical cardia sounds were 86-97 for saliva and 95-100 for water in two normal subjects for the evaluation of reproductibility (one man and one woman 35 and 47 years old respectively, n = 234 sequencies, interval 20 s). Using the distance between the upper and lower microphones, the esophageal time transit can be measured. The signal was more unconstantly recorded for saliva 40 ± 44 in adults (n = 10) and 76 ± 17 in children (n = 7), than for 80 et 87 for water respectively. The optimal interval between two swallows appeared to be 15-25 s. In patients with presumption of achalasia (n = 8), the two phonic signals were recorded during esophageal pressure measurement. The presence of esophageal sounds seems to be the sign of absence of achalasia.

To evaluate the safety and clinical efficacy of botulinum toxin (BT) in patients with achalasia followed up for six months.

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Copyright of Acta Endoscopica is the property of Lavoisier and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)