Helicobacter Pylori

This unusual name identifies a specific bacteria that can cause infection of the stomach. This infection can contribute to the development of diseases, such as dyspepsia (heartburn, bloating and nausea), gastritis (inflammation of the stomach), and ulcers in the stomach and duodenum. It will be useful to know some things about the upper digestive tract to understand how and where Helicobacter pylori infection can occur. When food is swallowed, it passes through the esophagus (the tube that connects the throat to the stomach). It then enters the larger upper part of the stomach. A strong acid that helps to break down the food is secreted in the stomach. The narrower, lower part of the stomach is called the antrum. The antrum contracts frequently and vigorously, grinding up the food and squirting it into the small intestine.

The duodenum is the first part of the small intestine, just beyond the stomach. The stomach, including the antrum, is covered by a layer of mucous that protects it from the strong stomach acid. It is known that alcohol, aspirin, and arthritis drugs such as ibuprofen can disrupt the protective mucous layer. This allows the strong stomach acid to injure underlying stomach cells. In some people, corticosteroids, smoking, and stress appear to contribute in some way. Until the mid 1980s, it was felt that one or more of these factors working together led to the development of gastritis and ulcers. Since that time, evidence has been mounting that Helicobacter pylori (H. pylori) has a major role in causing these diseases.

The Infection

H. pylori is a fragile bacteria that has found an ideal home in the protective mucous layer of the stomach. These bacteria have long threads protruding from them that attach to the underlying stomach cells. The mucous layer that protects the stomach cells from acid also protects H. pylori. These bacteria do not actually invade the stomach cells as certain other bacteria can. The infection, however, is very real and it does cause the body to react. Infection-fighting white blood cells move into the area, and the body even develops H. pylori antibodies in the blood. H. pylori infection probably occurs when an individual swallows the bacteria in food, fluid, or perhaps from contaminated utensils. The infection is likely one of the most common worldwide. The rate of infection increases with age, so it occurs more often in older people. It also occurs frequently in young people in the developing countries of the world, since the infection tends to be more common where sanitation is poor or living quarters are cramped. In many cases it does not produce symptoms. In other words, the infection can occur without the person knowing it. The infection remains localized to the gastric area, and probably persists unless specific treatment is given.

How is H. pylori Infection Diagnosed?

There are currently three ways to diagnose H. pylori infection. During endoscopy (a visual exam of the stomach through a thin, lighted, flexible tube), the physician can remove small bits of tissue through the tube. The tissue is then tested for the bacteria. A breath test is now available. In this test, a substance called urea is given by mouth. A strong enzyme in the bacteria breaks down the urea into carbon dioxide, which is then exhaled and can be measured. Finally, there is a blood test that measures the protein antibodies against these bacteria that are present in the blood. This antibody can mean the infection is present, or that it was present in the past and is now cleared. In other words, a person can have a positive blood test but no infection.

Gastritis and Dyspepsia

The symptoms are discomfort, bloating, nausea and perhaps vomiting. The person may also have symptoms that suggest ulcers such as burning or pain in the upper abdomen, usually occurring about an hour or so after meals or even during the night. The symptoms are often relieved temporarily by antacids, milk, or medications that reduce stomach acidity. Yet, the physician does not find an ulcer when the patient is tested by x-ray or endoscopy. When H. pylori is found in the stomach, it is tempting to believe that it is the cause of the symptoms, although this connection is not yet clear cut. The physician will usually prescribe antibiotic therapy to see if clearing the infection relieves symptoms.

Ulcers Stomach Ulcers: With stomach ulcers, H. pylori infection is found in 60 to 80 percent of the cases. Again, it is still uncertain how the infection acts to cause the ulcer. It probably weakens the protective mucous layer of the stomach. This allows acid to seep in and injure the underlying stomach cells. However, there is still a great deal of research to be done to unravel this relationship.

Duodenal ulcers: In times past, physicians were taught "no acid, no ulcer." The medical profession felt the single most important factor causing duodenal ulcers to form was strong stomach acid. Research has now shown that over 90% of all patients who develop duodenal ulcers have H. pylori infection in the stomach as well. Medical studies are under way to determine the relationship between the two and how an infection in the stomach can be related to a duodenal ulcer. Acid is still an important factor; patients without acid in the stomach never get duodenal ulcers. However, physicians now accept the fact that the infection is directly related to the development of duodenal ulcers. It is now rather easy to clear duodenal ulcers with the strong acid-reducing medicines available, but the ulcers will usually recur unless the H. pylori infection is also cleared from the stomach.

Stomach Cancer and Lymphoma

These two types of cancer are now known to be related to H. pylori bacteria. This does not mean that all people with H. pylori infection will develop cancer; in fact, very few do. It is likely that if the infection is present for a long time, perhaps from childhood, these cancers may then develop. This is another reason why it is important to treat H. pylori infection.

When is Treatment Necessary?

Since the infection is so common, it is sometimes recommended that no treatment be given when there are no symptoms; however, these recommendations may change as more research develops. Increasingly, physicians are treating the acute ulcer with acid-reducing medicines and treating the infection with antibiotics. Interestingly, one of these antibiotics is a bismuth compound that is available over-the-counter as Pepto-Bismol. It is also available as a generic drug called bismuth subsalicylate. The bismuth part of the medicine actually kills the bacteria; however, do not go to the drugstore and purchase a bottle of Pepto-Bismol, expecting this alone to cure the infection. H. pylori is buried deep in the stomach mucous, so it is difficult to get rid of this infection. Several antibiotic drugs are always used together to prevent the bacteria from developing resistance to any one of them. Current medical studies are being done to develop easier treatment programs for this difficult infection.

Summary

H. pylori is a very common infection of the stomach. It may be the most common infection in the world. It is now clear that the infection is directly related to the development of stomach and duodenal ulcers, and it is likely that it may be related to cancers involving the stomach. There are several diagnostic tests available, and effective treatment can prevent the recurrence of ulcers and perhaps the development of cancer

Adapted:Jackson-Siegelbaum Gastroenterology

Dyspepsia

Dyspepsia, also called indigestion, is a problem that most adults experience at least once in their lifetime. Upper abdominal discomfort, nausea, vomiting, and belching are all symptoms of dyspepsia. Indigestion is often related to consumption of too much food, especially heavy or greasy foods, eating late at night, smoking, alcohol consumption, or life stress. For some individuals, dyspepsia occurs regularly and becomes a health and quality-of-life issue. The April 5, 2006, issue of JAMA includes an article about dyspepsia.

SYMPTOMS

· Upper abdominal discomfort

· Sensation of bloating

· Nausea with or without vomiting

· Belching

· Abdominal gas

· Feeling full after eating small amounts (called early satiety

WHEN TO SEE YOUR DOCTOR

Because symptoms similar to those of dyspepsia may indicate a serious medical condition, you should see your doctor if you have indigestion on a regular basis. If you have bloody stools or vomit blood you should see a doctor immediately. Medical problems that have similar symptoms include gastroesophageal reflux disease (known as GERD), peptic ulcer disease, stomach cancer, pancreatic cancer, pancreatitis, gallbladder disease, irritable bowel syndrome, and even heart disease (upper abdominal pain may be due to angina or heart attack).

TESTING

Because dyspepsia can be a symptom of an underlying medical problem, your doctor may prescribe tests to look for these other conditions. These tests may include a barium swallow (an x-ray test in which the patient swallows a barium-containing solution to outline the gastrointestinal tract), upper gastrointestinal endoscopy (a lighted tube is passed through the esophagus into the stomach to look for abnormalities), or computed tomography (CT scan).

TREATMENT AND PREVENTION

• Avoid foods that trigger your dyspepsia symptoms.
• Avoid factors that make indigestion worse, such as eating large meals, especially heavy or greasy foods, eating late at night, eating quickly, or eating before exercise.
• Do not smoke.
• Avoid alcohol, if it produces symptoms of dyspepsia.
• Maintain a healthy weight, which helps to reduce symptoms of dyspepsia.
• Exercise regularly (at least 30 minutes of moderate to vigorous physical activity on most days of the week) to reduce stress, control weight, and improve well-being, all of which may ease dyspepsia.
• Follow your doctor's recommendations regarding medications for treating dyspepsia. These may include antacids, proton pump inhibitors, histamine-2 receptor blockers, and motility drugs (to help the stomach empty). Other medications may be prescribed for individuals with other medical problems that influence the symptoms of indigestion.
  

Adapted from: JAMA Patient Page

Pancreatitis

The pancreas is a gland that sits behind the stomach. Larger than your gallbladder, but smaller than the liver, the pancreas plays a key role in the digestive system. Its juices join bile from the liver and gallbladder to drain into the small intestine. Specifically, the pancreas:

• Secretes digestive juices (enzymes and a substance called sodium bicarbonate) into the small intestine
• Produces the hormones, including insulin and glucagon, that control your body’s ability to use sugar

The digestive substances split the fats, proteins, and carbohydrates into digestible molecules.

What is Pancreatitis?

Pancreatitis is inflammation of the pancreas. This condition usually begins at an acute stage, and in some cases, may become chronic after a severe and/or recurrent attack. When the pancreas becomes inflamed, the digestive enzymes attack the tissue that produces them. One of these enzymes, called trypsin, can cause tissue damage and bleeding, and can cause the pancreas blood cells and blood vessels to swell. With chronic pancreatitis, the pancreas may eventually stop producing the enzymes that are necessary for your body to digest and absorb nutrients. This is called exocrine failure and fat and protein are not digested or absorbed. When chronic pancreatitis is advanced, the pancreas can also lose its ability to make insulin; this is called endocrine failure.

There are two stages of pancreatitis:

Acute pancreatitis: This condition can occur suddenly, soon after the pancreas becomes damaged or irritated by its own enzymes. Although acute pancreatitis is not fully understood, its causes are usually gallstones or alcohol abuse. When gallstones pass through the bile duct, they may become stuck, causing enzymes to build up in the pancreas because they cannot drain through the duct, and damaging the pancreas. In the case of alcohol, the pancreas may be sensitive to the effects of excessive alcohol. An attack may occur anywhere from a few hours or one to two days after drinking alcohol. The amount of alcohol consumed will vary from person to person. Other less common causes of this condition are: excessive levels of fat particles in the blood, mumps, drugs, surgery, heredity, and idiopathic (unknown cause). Acute pancreatitis affects about 80,000 Americans every year.

Chronic pancreatitis: This stage of pancreatitis begins as acute pancreatitis, and becomes chronic when the pancreas becomes scarred. This condition is usually due to years of excessive alcohol consumption, but may also develop from other causes of pancreatitis.

What are the Symptoms of Pancreatitis?

The symptoms begin as those of acute pancreatitis:

• A gradual or sudden severe pain in the center part of the upper abdomen goes through to your back; this pain may get worse when you eat and builds to a persistent pain
• Nausea and vomiting
• Fever
• Jaundice (a yellowing of the skin) due to blockage of the bile duct from the inflamed pancreas
• Shock
• Weight loss
• Symptoms of diabetes mellitus

Most chronic pancreatitis is due to alcohol abuse and is already chronic at its first presentation. In rare cases this condition leads to cancer of the pancreas, an unchecked growth of abnormal cells in the pancreas.

What Should I Do If I Think I Have Pancreatitis?

If your abdominal pain lasts more than 20 minutes, call your doctor or go to the emergency room. Your doctor will take a medical history, ask about your drinking history, and draw blood to test for pancreatic enzymes. You may also need to take pancreas function tests to determine the loss of pancreatic enzymes, a fecal fat collection test for evidence of malabsorption, and an ultrasound, CT scan or other test to determine pancreas damage.

If you have unexplained weight loss that lasts more than a few weeks, call your doctor. This can be a warning sign of pancreatic cancer.

What is the Difference Between Acute and Chronic Pancreatitis?

Most cases of acute pancreatitis are mild and involve a short hospital stay to help heal the pancreas. Chronic pancreatitis is a much more persistent condition, and occurs more often in men than women.

What is the Treatment for Pancreatitis?

Your doctor will focus treatment on your nutritional and metabolic needs and on relieving your pain. Mild pain can be treated with analgesics. If the cause of acute pancreatitis is gallstones, you may have to have your gallbladder removed to prevent further attacks. If the bile duct is found to be enlarged, you may need an ERCP (endoscopic retrograde cholangiopancreatography) to drain it. An ERCP is a way your doctor can examine your pancreas, pancreatic duct, the common bile duct, and/or sphincter of Oddi. It involves passage of a long, narrow tube called an endoscope used to put X-ray contrast dye into the bile and pancreas ducts. In severe cases, surgery will be required to drain the pancreatic duct or to remove part of the pancreas.

Your doctor will also likely give you dietary guidelines to follow in order to reduce the amount of fat you eat, since your body has trouble digesting these substances. You may also need to take pancreatic enzyme supplements, which are in the form of a tablet, every time you have a meal. These supplements will help your body absorb food and help you regain some of the lost weight.

What Hope for the Future?

Most people who have chronic pancreatitis have a good prognosis if they follow the required dietary changes and take their medications and required supplements. If their condition was caused by drinking, they will have a positive outcome if they stop drinking and continue follow-up treatment.

PREVENTION OF PANCREATITIS

While pancreatitis is still not fully understood, there are some steps you can take to prevent pancreatitis from occurring again:

• If the cause is gallstones and your gallbladder has not been removed, avoid fatty foods, such as butter and fried eggs
• If the cause is alcohol, you should stop drinking altogether

Glossary

Acute pancreatitis - The initial stage of pancreatitis, characterized by gradual or sudden severe pain in the center part of the abdomen that moves around to the back, signaling a damaged or irritated pancreas.

Bile - A secretion of the liver that helps digest fats in the intestines.

Biliary system - The ducts and tubes that collect and drain bile.

Chronic pancreatitis - Occurs when the symptoms of acute pancreatitis continue to recur. Usually due to years of excessive alcohol consumption, this condition may also develop from other causes of pancreatitis.

ECRP (Endoscopic Retrograde Cholangiopancreatography) - A long, narrow tube called an endoscope used to examine the pancreas, pancreatic duct, common bile duct, and/or sphincter of Oddi. The scope can be used to put contrast dye into the pancreas to highlight stones or blockages, and can be used to remove blockages.

Diabetes mellitus - A condition where the pancreas does not produce enough insulin to use carbohydrates.

Endocrine - An internal gland secretion--directly into the blood stream.

Exocrine - The external secretion of a gland-through a duct into the intestine.

Inflammation - A response to tissue injury that causes redness, swelling, and sometimes pain.

Jaundice - The skin and/or white of the eyes turns yellow. Itching may or may not occur.

Pancreas- A gland that sits behind the stomach, and produces insulin to metabolize sugar and secretes enzymes to breakdown fats, proteins, and carbohydrates.

Pancreatic duct - Drains pancreatic enzymes into the small intestine.

Sphincter of Oddi - A circular, contracting muscle at the intestinal opening of the bile and pancreatic ducts.

Adapted from: American Gastroenterological Association

Hirschsprung's Disease

Hirschsprung's (say: "hersh-sprungz") disease is a birth defect that affects the large intestine (bowel). Normally, nerve cells called ganglion (say: "gang-glee-on") cells stimulate muscles in the intestine to push stools through the intestine and out of the body. A child born with Hirschsprung's disease is missing these nerve cells in a part of the intestine. As a result, stools do not move properly through the intestine and severe constipation and even bacterial infection can develop. Sometimes the ganglion cells are missing from just a small part of the large intestine near the anus. Other times, the cells may be missing from a large part of the large intestine.

What causes Hirschsprung's disease?

As a baby grows in the womb, the ganglion cells grow from the top of the intestine to the anus. When a baby has Hirschsprung's disease, these nerve cells don't grow all the way to the anus. Doctor's don't know why the nerve cells stop growing, but it isn't caused by anything the mother did or ate while she was pregnant.

Hirschsprung's disease can be hereditary, meaning a parent could pass it on to a child. Children with Down syndrome are at a higher risk of having Hirschsprung's disease. The disease, which affects about 1 in every 5,000 newborns, is five times more frequent in males than in females.

What are the symptoms of Hirschsprung's disease?

Hirschsprung's disease is usually diagnosed shortly after birth, but in some milder cases, symptoms don't develop until later in life. You or your doctor may notice that your newborn did not pass the first bowel movement, called the meconium, in the first 24 to 48 hours after birth. Your newborn may also have some or all of the following symptoms:

• Constipation or gas, which may make your baby fussy
• Poor appetite
• Vomiting bile (a green liquid) after eating
• Diarrhea

Symptoms in older children include the following:

• Chronic constipation
• Lack of weight gain or growth
• Swollen abdomen
• Ribbon-like, foul-smelling stools
• Anemia (which is a low number of red blood cells)
• Frequent colon infections

How can my doctor tell if my baby has Hirschsprung's disease?

If your child exhibits symptoms of Hirschsprung's disease, your doctor may give your child several special tests. Your doctor may take an X-ray of your child's abdomen or give your child a barium enema to look for signs of Hirschsprung's disease. Your doctor may also take a sample of tissue (called a biopsy) from your child's rectum and examine it for missing ganglion cells.

How is Hirschsprung's disease treated?

Surgery is the only proven way to treat Hirschsprung's disease. The surgeon will remove the part of the intestine that is missing the ganglion cells and reattach the healthy intestine to the anus. After your child heals, he or she will have a functioning intestine.

For children who have been very ill, two surgeries may be needed. In the first surgery, called a colostomy, the surgeon will remove the area of the intestine that is missing the ganglion cells. The surgeon then creates a small hole (called a stoma) in your child's abdomen. The top part of the intestine is then attached to the stoma. For a while, stool leaves the body into a collection bag attached to the stoma while the rest of the intestine heals. In a second operation, the surgeon will connect the healed intestine to the anus and sew the stoma closed.

What will my child's life be like after surgery?

Most children have normal lives after surgery. Some children may have diarrhea. Other children may have problems passing stools. Eating foods that are high in fiber can help reduce constipation.

Some children develop infections in their bowels after surgery. These infections can be serious, so call your doctor immediatetly if your child develops the following symptoms:

• Vomiting
• Fever
• Swollen abdomen
• Fatigue or sluggishness
• Blood in the stool

The large intestine collects water and salt that the body needs. If your child has a large portion of the intestine removed, it will absorb less. Your child will need to eat and drink more to make sure his of her body gets enough fluids.

Adapted from: American Academy of Family Physicians

Intussusception

Intussusception occurs when one portion of the bowel slides into the next, much like the pieces of a telescope. When this occurs, it creates an obstruction in the bowel, with the walls of the intestines pressing against one another. This, in turn, leads to swelling, inflammation, and decreased blood flow to the intestines involved.

The most common cause of intestinal obstruction in children between the ages of 3 months and 6 years, intussusception:

• occurs most often in children between 5 and 10 months of age (80% occur before a child is 24 months old)
• affects between one and four infants out of 1,000
• is three to four times more common in boys than in girls

Signs and Symptoms

Children with an intussusception have intense abdominal pain, which often begins so suddenly that it causes loud, anguished crying and causes the child to draw the knees up to the chest. The pain is usually intermittent, but recurs and becomes stronger. As the pain subsides, a child with an intussusception may stop crying and seem fine.

Other common symptoms include:

• abdominal swelling or distension
• passing stools (or poop) mixed with blood and mucus, known as currant jelly stool (60% percent of infants with an intussusception will pass currant jelly stool)
• vomiting
• vomiting up bile, a bitter-tasting fluid secreted by the liver that's often golden-brown to greenish in color
• lethargy (i.e., drowziness or sluggishness)
• shallow breathing
• grunting

As the illness progresses, a child will become progressively weaker and may develop a fever and appear to go into shock. Symptoms of shock include lethargy, rapid heartbeat, weak pulse, low blood pressure, and rapid breathing.

Causes

In infants, the causes of intussusception are unknown, although there are some theories about why it occurs. Because intussusception is seen most often in spring and fall, this seems to suggest a possible connection to the kinds of viruses that children catch during these seasons, including upper respiratory infections.

In some cases, intussusception may follow a recent bout of gastroenteritis (sometimes called stomach flu). Gastrointestinal infections may cause swelling of the infection-fighting lymph tissue that lines the intestine, which may pull one part of the intestine into the other. Intussusception is most common around the age that infants are being introduced to solid foods. It has been suggested that the introduction of new foods may also cause some swelling of the lymph tissue in the intestines, increasing the chance of developing an instussusception.

Usually when an adult or a child older than 3 develops an intussusception, it's often the result of enlarged lymph nodes, a tumor, or a polyp in the intestine.

Diagnosis and Treatment

The doctor will then perform a physical exam on the child, paying special attention to the abdomen. Often, the doctor can feel the part of the intestine that's involved, which is swollen and tender and often is described as a "sausage-shaped mass." Symptoms like pain, drawing up the legs, vomiting, lethargy, and passing bloody or currant jelly stool are meaningful in helping the doctor reach a diagnosis. In addition to doing a physical examination, the doctor will ask the parent about any concerns and symptoms their child has, the child's past health, your family's health, any medications the child is taking, any allergies the child may have, and other issues. This is called the medical history.

If the doctor thinks an intussusception may be the cause of the child's pain, a pediatric surgeon will be consulted to examine the child and decide about treatment. The doctor may order an abdominal X-ray, which may or may not show an obstruction. An ultrasound examination may also help make the diagnosis. If the child appears very ill, suggesting damage to the intestine, the surgeon may opt to take the child immediately to the operating room to correct the bowel obstruction.

A barium or air enema is often used to both diagnose and treat a suspected intussusception. During a barium enema, a liquid mixture containing barium is given through a catheter tube into the child's rectum, and special X-rays are taken. Barium outlines the bowels on the X-rays and, if an intussusception is present, shows the doctors the telescoping piece of intestine.

In many instances, the barium enema not only shows the intussusception, but the pressure from putting it in the bowel may also unfold the bowel that has been turned inside out, instantly curing the obstruction. An air enema, given rectally in a similar way as barium, can also be used to diagnosis and treat an intussusception.

The radiologist usually decides which test is most appropriate to perform. Both procedures are very safe and usually well tolerated by the child, although there is a very small risk of infection or bowel perforation. There's a 10% risk of recurrence, which usually occurs within 72 hours following the procedure.

If the barium or air enema procedures aren't successful or the child is too ill to attempt the enema, the child will undergo surgery. Enemas are less successful in older children, and they're more likely to require surgery to treat intussusception. Surgeons will try to fix the obstruction but if too much damage has been done, that part of the bowel will be removed.

Some babies with intussusception may be given antibiotics to prevent infection. Babies who have been treated for intussusception will be kept in the hospital and given intravenous feedings until they're able to eat and have normal bowel function.

Complications

If left untreated, intussusception can cause severe complications. Complications are directly related to the amount of time that passes from when the intussusception occurred until it's treated. Most infants who are treated within the first 24 hours recover completely from an intussusception with no problems. Further delay increases the risk of complication which include irreversible tissue damage, perforation of the bowel, infection, and death.

When to Call Your Child's Doctor

Intussusception is a medical emergency. If you're concerned that your child has some or all of the symptoms of intussusception, such as abdominal pain, vomiting, or passing of currant jelly stool, call you child's doctor or emergency medical services immediately.

The outcome for most infants with intussusception is very good, and with early treatment, complications are much less likely to develop. Do not delay, though — in many cases, early diagnosis can mean a child can be successfully treated without surgery

Adapted from: Nemours Foundation

Esophageal Achalasia

Esophageal achalasia is a primary esophageal motility disorder of unknown etiology, characterized by absence of esophageal peristalsis and increased or normal resting pressure of the lower esophageal sphincter (LES), which fails to relax completely in response to swallowing.

Clinical Presentation

Dysphagia is the most common symptom, experienced by virtually all patients. Regurgitation is the second most common symptom, and is present in about 60% of patients. It occurs more often in the supine position, and exposes the patients to the risk of aspiration of undigested food. Chest pain occurs in about 40% of patients, and is usually experienced at the time of a meal. Heartburn is experienced by about 40% of patients. In untreated patients this symptom is usually due to stasis and fermentation of food or esophageal distension.

Diagnosis

In addition to careful symptomatic evaluation, the following tests should be routinely performed: Barium swallow usually shows narrowing at the level of the gastroesophageal junction ("bird beak"), and various degrees of esophageal dilatation. Endoscopy is important to rule out the presence of a peptic stricture or cancer, and gastroduodenal pathology. In patients older than 60 years of age, with recent onset of dysphagia and excessive weight loss, secondary or pseudo-achalasia (obstruction due to a submucosal neoplasm in the distal esophagus) should be ruled out. Because a cancer of the gastroesophageal junction is the most common cause of pseudo-achalasia, an endoscopic ultrasound or a CT scan of the gastroesophageal junction can help to establish the diagnosis. Esophageal manometry is the key test for establishing the diagnosis. The classic manometric findings are: (a) absence of esophageal peristalsis, and (b) hypertensive or normotensive LES which fails to relax completely in response to swallowing.

Treatment

Treatment is directed toward elimination of the outflow resistance at the level of the gastroesophageal junction. The following treatment modalities are available to achieve this goal:

Traditionally, pneumatic dilatation has been the first line of treatment for esophageal achalasia, while surgery was reserved for patients who had persistent dysphagia after multiple dilatations or who had suffered a perforation during dilatation. Today, minimally invasive surgery has completely changed this treatment algorithm and a laparoscopic Heller myotomy and partial fundoplication is preferred by most gastroenterologists and surgeons as the primary treatment modality. When properly performed, a Heller myotomy can be expected to result in permanent relief of dysphagia in 85-100% of patients. Critical details of the operation include a generous myotomy of the lower esophagus, extending well onto the gastric wall. Because of the lack of esophageal peristalsis, a partial (Dor or Toupet), rather than a total fundoplication is frequently added to prevent reflux. A recent prospective, randomized study demonstrated that Heller myotomy plus a partial fundoplication is superior to Heller myotomy alone in regard to the incidence of postoperative reflux as measured by 24 hour pH testing. Patients can usually eat the morning of the first postoperative day, and can be discharged home after one or two days. In the only prospective, randomized trial performed comparing balloon dilation with surgery, myotomy outperformed balloon dilation 95% to 65%.

Historically, the most popular treatment for achalasia has been by forceful pneumatic dilation. The success rate of this procedure is 55-70% with a single dilation but can be increased to nearly 90% with multiple dilations. However, the risk of perforation with each dilation is at least 3-5% and has been reported as high as 12% in some series. These patients may require open surgery to close the perforation and perform a myotomy. Furthermore, when stratified by age, balloon dilation is less than 50% effective in patients younger than 40 years old and is rarely effective in adolescents.

Intrasphincteric injection of botulinum toxin (BOTOX) injection is less effective than balloon dilation and requires re-treatment to maintain an efficacy rate of 65%. Of greater concern is the fact that BOTOX injection leads to scar formation in the submucosal plane which results in a more difficult myotomy and higher mucosal perforation rate (up to 30%) during dissection. Thus, BOTOX should be reserved for the treatment of patients who are poor candidates for surgery and poor candidates for balloon dilation (dilated sigmoid esophagus) or as a bridge to surgery. An additional utility for BOTOX is in aiding in the diagnosis of patients who have equivocal findings on initial evaluation. A good response to BOTOX is usually an indication that the patient will have long-term relief following surgical myotomy.

In selected patients such as a hostile, multiply operated abdomen or following a failed abdominal myotomy, the thoracic or thoracoscopic approach may be preferred. The thoracic approach is also appropriate in managing patients with proximal esophageal motility abnormalities.

Occasionally the degree of esophageal aperistalsis is so advanced that myotomy alone will not relieve the dysphagia and the patient is better served with esophagectomy. Esophagectomy should be considered in a patient who has had a previous myotomy, with a resting LES pressure of less than 10 mmHg, and a dilated sigmoid esophagus. The need for esophagectomy for achalasia is very uncommon, even in the presence of a dilated esophagus, and should be reserved for failures after myotomy.

All patients undergoing treatment for achalasia should be followed by surveillance endoscopy, because they are at increased risk for development of both squamous and adenocarcinoma.

Risks

Aspiration of retained food in the esophagus at the time of induction of anesthesia and perforation of the esophageal mucosa are the most common operative complications. Persistent or recurrent dysphagia occurs in 5% to 10% of patients. The combination of intraoperative manometry and endoscopy can better guide the extent of the myotomy and can improve the adequacy of myotomy and are useful tools in decreasing the incidence of significant dysphagia after antireflux surgery. A complete work-up is necessary to evaluate the cause of the dysphagia in these patients, and either pneumatic dilatation or a second operation can often correct the problem. Up to 15% of patients may experience gastroesophageal reflux after myotomy, as measured by pH monitoring. In patients undergoing elective myotomy the mortality rate is less than 1%.

Expected Outcomes

About 90% of patients have long-term relief of dysphagia after a myotomy, with a low incidence of symptomatic acid reflux. There is often a poor correlation between symptoms of reflux and measurable reflux as demonstrated by pH study. All patients should be studied by postoperative pH study. Patients with demonstrated reflux by pH study or with reflux symptoms after surgery should be treated long-term with proton pump inhibitors.

Adapted from: Society for Surgery of the Alimentary Tract

Amebiasis, Ascariasis

Amebiasis is an intestinal illness caused by a microscopic parasite called Entamoeba histolytica. Approximately 1,000 cases are reported each year in New York State.

Who gets amebiasis?

Anyone can get amebiasis, but it is recognized more often in people arriving from tropical or subtropical areas, individuals living in institutions, and men who have sex with men.

How is amebiasis spread?

Amebiasis is contracted by consuming contaminated food or water containing the cyst stage of the parasite. It can also be spread by person-to-person contact.

What are the symptoms of amebiasis?

People exposed to this parasite may experience mild or severe symptoms or no symptoms at all. Fortunately, most exposed people do not become seriously ill. The mild form of amebiasis includes nausea, loose stools, weight loss, abdominal tenderness and occasional fever. Rarely, the parasite will invade the body beyond the intestines and cause a more serious infection, such as a liver abscess.

How soon after exposure do symptoms appear?

The symptoms may appear from a few days to a few months after exposure but usually within two to four weeks.

For how long can an infected person carry this parasite?

Some people with amebiasis may carry the parasite for weeks to years, often without symptoms.

Where are the parasites that cause amebiasis found?

The parasite lives only in humans. Fecal material from infected people may contaminate water or food, which may spread the parasites to anyone who consumes them.

How is it diagnosed?

Examination of stools under a microscope is the most common way for a doctor to diagnose amebiasis. Sometimes, several stool samples must be obtained because the number of amoeba being passed in the stool, which varies from day to day, may be too low to detect from any single sample.

What is the treatment for amebiasis?

Specific antibiotics such as metronidazole can be prescribed by a doctor to treat amebiasis.

Should an infected person be excluded from work or school?

Although people with diarrhea due to amebiasis should not attend school or go to work, it is not necessary to exclude infected persons when they feel better and stools are normal. Casual contact at work or school is unlikely to transmit the disease. Special precautions may be needed by foodhandlers or children enrolled in daycare settings. Consult your local health department for advice in such instances.

What precautions should the infected person follow?

The most important precautions are careful handwashing after each toilet visit and proper disposal of sewage. Homosexual males should refrain from intimate contact until effectively treated.

Adapted from: New York State Department of Health

Ascariasis

The disease and how it affects people

Ascariasis is an infection of the small intestine caused by Ascaris lumbricoides, a large roundworm. The eggs of the worm are found in soil contaminated by human faeces or in uncooked food contaminated by soil containing eggs of the worm. A person becomes infected after accidentally swallowing the eggs. The eggs hatch into larvae within the person's intestine. The larvae penetrate the intestine wall and reach the lungs through the blood stream. They eventually get back to the throat and are swallowed. In the intestines, the larvae develop into adult worms. The female adult worm which can grow to over 30cm in length, lays eggs that are then passed into the faeces. If soil is polluted with human or animal faeces containing eggs the cycle begins again. Eggs develop in the soil and become infective after 2-3 weeks, but can remain infective for several months or years.

Children are infected more often than adults, the most common age group being 3-8 years. The infection is likely to be more serious if nutrition is poor. They often become infected after putting their hands to their mouths after playing in contaminated soil. Eating uncooked food grown in contaminated soil or irrigated with inadequately treated wastewater is another frequent avenue of infection.

The first sign may be the passage of a live worm, usually in the faeces. In a severe infection, intestinal blockage may cause abdominal pain, particularly in children. People may also experience cough, wheezing and difficulty in breathing, or fever.

Distribution

Ascariasis is found worldwide. Infection occurs with greatest frequency in tropical and subtropical regions, and in any areas with inadequate sanitation.

Scope of the Problem

Ascariasis is one of the most common human parasitic infections. Up to 10% of the population of the developing world is infected with intestinal worms – a large percentage of which is caused by Ascaris. Worldwide, severe Ascaris infections cause approximately 60,000 deaths per year, mainly in children.

Interventions

Health education providing the following messages reduces the number of infected people:

• avoid contact with soil that may be contaminated with human faeces;
• wash hands with soap and water before handling food;
• wash, peel or cook all raw vegetables and fruits;
• protect food from soil and wash or reheat any food that falls on the floor.

The availability of water for use in personal hygiene as well as proper disposal of human faeces will also reduce the number of cases. Where wastewater is used for irrigation waste stabilization ponds and some other technologies are effective in decreasing transmission due to food grown in contaminated soil.

Infected individuals (and domestic animals) should be treated with medicine to reduce disease transmission. Ascariasis can be effectively treated with mebendazole or pyrantel pamoate.

Adapted from: WHO