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Disorders of esophageal motility have been described in patients with cirrhosis in a small number of studies. In this review, we aim to provide an overview of the available evidence on esophageal motility disorders in cirrhosis and their clinical implications. This review delves into the following concepts: (1) Gastroesophageal reflux disease is common in liver cirrhosis due to many mechanisms; however, when symptomatic it is usually nocturnal and has an atypical presentation; (2) Endoscopic band ligation is better than sclerotherapy in terms of its effect on esophageal motility and seems to correct dysmotilities resulting from the mechanical effect of esophageal varices; (3) Chronic alcoholism has no major effects on esophageal motility activity other than lower esophageal sphincter hypertension among those with alcoholic autonomic neuropathy; (4) An association between primary biliary cholangitis and scleroderma can be present and esophageal hypomotility is not uncommon in this scenario; and (5) Cyclosporin-based immunosuppression in liver transplant patients can have a neurotoxic effect on the esophageal myenteric plexus leading to reversible achalasia-like manifestations.

Background and study aims Some patients with dysplastic Barrett’s esophagus (BE) experience suboptimal response to radiofrequency ablation (RFA), endoscopic mucosal resection (EMR), or the combination. Cryotherapy has been used as salvage therapy in these patients, but outcomes data are limited. We aimed to assess clinical outcomes among a large cohort of patients with dysplastic BE whose condition had failed to respond to RFA and/or EMR. Patients and methods This was a retrospective cohort study of consecutive cases of dysplastic BE or intramucosal carcinoma (IMC) treated with salvage cryotherapy at a tertiary-care academic medical center. The primary goal of cryotherapy treatment was eradication of all neoplasia. The secondary goal was eradication of all intestinal metaplasia. The proportion of patients undergoing salvage cryotherapy who achieved complete eradication of dysplasia (CE-D) and metaplasia (CE-IM), as well as the time to CE-D and CE-IM were calculated. Results Over a 12-year period, 46 patients received salvage cryotherapy. All patients underwent RFA prior to cryotherapy, either at our center or prior to referral, and 50 % of patients underwent EMR. A majority of patients (54 %) had high-grade dysplasia (HGD) at referral, while 33 % had low-grade dysplasia (LGD), and 13 % had IMC. Overall, 38 patients (83 %) reached CE-D and 21 (46 %) reached CE-IM. Median time to CE-D was 18 months, median number of total interventions (RFA, cryotherapy, and EMR) was five, and median number of cryotherapy sessions was two. Conclusion Salvage cryotherapy appears safe and effective for treating BE that is refractory to RFA and/or EMR.

Due to its smooth muscle relaxing properties, peppermint oil (PO) may relieve dysphagia and chest pain due to esophageal motility disorders. To explore the impact of PO on dysphagia and/or chest pain in patients referred for motility testing. Patients initiated on PO for dysphagia and/or chest pain from 2013 to 2016 were identified. We excluded patients with obstructing esophageal lesions, patients lost to follow-up, and those with preexisting cardiac conditions. Concentrated PO was given as commercially available dissolvable peppermint tablets; two tablets before meals were prescribed to patients with dysphagia and on an as-needed basis for patients with chest pain. Patient-reported symptom response was assessed using a modified five-point Likert scale. Thirty-eight patients were included. Twenty-four patients (63%) reported improvement; 12 were much better and 12 were slightly better. Fourteen experienced no change and none reported feeling worse. Based on pre-treatment HRM, patients with distal esophageal spasm (DES) (n = 10) and esophagogastric junction outflow obstruction (EGJOO) (n = 8) appeared to demonstrate the best subjective improvement (83% and 100%, respectively) (P

Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known as the weight loss surgery to which other bariatric procedures are compared. While morbidity and mortality of this procedure are low, serious complications do exist which can be life-threatening and sometimes require surgical correction. Case presentation A 63-year-old woman underwent LRYGB outside of the United States, later complicated by biliary colic treated with cholecystectomy and upper gastrointestinal bleeding secondary to H. pylori-related ulcer at her gastrojejunostomy. Following adequate treatment of the patients marginal ulcer, the patient experienced several months of progressive severe abdominal pain, frequent vomiting and diarrhea, and unintentional weight loss refractory to pharmacologic therapy. The patient underwent multiple medical and endoscopic evaluations unrevealing of an organic cause of her symptoms. At presentation, the patient was found to be profoundly weak, dehydrated and malnourished with metabolic derangements and was subsequently diagnosed with a gastrojejunocolic fistula via upper endoscopy and radiography. We provided excluded stomach gastrostomy tube feeding to the patient for three months to improve the patients nutritional status before definitive surgical correction was successfully performed. Discussion Large bowel fistulas are a rare and highly morbid late complication following LRYGB and are likely secondary to marginal ulcers and/or instrumentation such as endoscopy. Surgery represents the definitive treatment. Conclusion LRYGB is typically a safe and effective intervention for obesity. Large bowel fistulas are rare complications following this surgery. We highlight difficulties in diagnosing and treating this condition., Highlights • Morbidity and mortality of bariatric surgery have decreased since 1990s. • Large bowel fistulas are a rare, highly morbid complication after gastric bypass. • Important to optimize patient nutrition before correction of colonic fistulas

Distal esophageal spasm is a rare motility disorder presenting principally with nonobstructive dysphagia and noncardiac chest pain. In symptomatic patients, the manometric diagnosis is made when >10% of the wet swallows have simultaneous and/or premature contractions intermixed with normal peristalsis. We characterize manometry and barium as complementary diagnostic approaches, and given the intermittent nature of the disorder, one should be always aware that it is almost impossible to rule out spasm. Treatment is difficult; we propose an approach beginning with the least invasive intervention.

Alginates have been shown not only to be beneficial in their relief of symptomatic post-prandial gastroesophageal reflux, but there is also evidence that they may inhibit reflux, including bile acids and pepsin, and in turn attenuate and even prevent the activation and up-regulation of molecules associated with the development of metaplasia and cancer of the esophagus. Here we present the case of a patient with Barrett's esophagus with high-grade dysplasia (HGD) which was initially unresponsive to endoscopic radiofrequency ablation therapy and cryotherapy for highgrade dysplasia. Following initiation of therapy with an alginate solution in addition to twice daily proton pump inhibitor (PPI) therapy, the patient showed a favorable response and eventual complete eradication of his dysplastic Barrett's. The patient's course is suggestive that the alginate solution, through reflux inhibition, prevented persistent esophageal cell changes which occur secondary to gastric and bile acid exposure, thus allowing development of neosquamous epithelium. This case is intriguing with regard to the role of alginates in creating a favorable environment for esophageal healing when treating Barrett's esophagus with high-grade dysplasia.

To the Editor: We greatly enjoyed the thoughtful and very informative commentary by Jacobs and Richter carefully summarizing the senior author’s vast experience with pneumatic dilation (PD) as a primary treatment for achalasia (1). It was gratifying to note that as their experience has grown they have incorporated and refined this technique based on many aspects that we learned together as colleagues and now pass on to our junior "esophagologists." The one aspect of the approach to PD, as described that we would challenge, is the actual duration of inflation of the dilating balloon. Over the years that this procedure was evolving, we changed from holding the balloon through two steps to only one step of a full 60 s of inflation, an approach still being used by many experts. However, while watching the fluoroscopic image we wondered whether there was any necessity to leave the balloon inflated once the waist had been obliterated. It would seem that the situation had been accomplished at that point, usually by the early seconds of inflation.