CONTACTS
SUBJECTS
Gastrointestinal (GI) Clinic Meeting Evaluate Digestion Problem Poss
1103 -
1103 - ..
1104 - Summary/Objective
1105 -
110501 - Follow up ref SDS 26 0000. ref SDS 25 0000.
110502 -
110503 - Image and blood tests indicate diagnosis of primary achalasia.
110504 - ref SDS 0 5B5K Several treatments are available; the doctor proposes
110505 - pneumatic dilation, ref SDS 0 NZ4G, after performing due diligence to
110506 - verify diagnosis, beginning with endoscopy scheduled for next week on
110507 - 051209. ref SDS 0 NZ5H The doctor further recommends for preventive
110508 - medicine and generally unrelated to achalasia, colonoscopy testing,
110509 - since this was last performed with sigmoidoscopy about five (5) years
110510 - ago, and so follow up is now due. ref SDS 0 WO6H After meeting with
110511 - the doctor, a nurse submitted instructions to prepare for the
110512 - endoscopy procedure. ref SDS 0 GM8G Key point is no solid food for 48
110513 - hours, and no liquid for 12 hours prior to the procedure. ref SDS 0
110514 - EP9H There is also an explanation of the endoscopic examination.
110515 - ref SDS 0 IA5I
110516 -
110517 - [On 051207 submitted the record for feedback. ref SDS 28 0001
110519 - ..
110520 - [On 051209 endoscopy examination preliminary findings no evidence
110521 - of cancer, ref SDS 29 0001; biopsy report should be submitted in a
110522 - few weeks to confirm status of cancer, ref SDS 29 PY5J, and if so,
110523 - then a procedure can be schedule for next month to dilate the
110524 - exophageal sphincter valve. ref SDS 29 NZ5H
110525 -
110526 -
110527 -
110528 -
110529 -
110531 - ..
1106 -
1107 -
1108 - Progress
1109 -
110901 - Meeting Gastrointestinal Department Evaluate Digestion Problem
110902 -
110903 - Meeting ordered on referral 4 months ago from primary care physician
110904 - during meeting on 050816. ref SDS 21 0G7M
110906 - ..
110907 - This referral complements prior testing....
110908 -
110909 - Barium test report.............. 050830, ref SDS 23 UR3M
110910 - Ultrasound report............... 050906, ref SDS 24 BM6R
110911 - Endoscopy meeting delayed....... 051116, ref SDS 26 TP4L
110912 - Endoscopy scope................. 051202, ref SDS 0 IA5I
110913 -
110915 - ..
110916 - Vitals taken...
110917 -
110918 - Blood pressure 117 70
110919 - Pulse 79
110920 -
110921 -
110922 -
110924 - ..
1110 -
1111 -
1112 - 1448
1113 -
111301 - Meeting Doctor...
111302 -
111304 -
111305 -
111306 -
111307 -
111308 -
1114 -
SUBJECTS
Family History Digestion Problems No Knowledge on History of Achalas
1603 -
160401 - ..
160402 - Family History Digestion Problems No Knowledge on History of Achalasia
160403 - Personal History Digestion Issues and Record Prior Investigations
160404 -
160405 - The doctor asked about medical history.
160406 -
160407 - Father and mother suffered unknown digestion issues, but which seem
160408 - unrelated to achalasia. Father died at age 65 of stroke in 1979.
160409 - Mother is living at age 80 and suffers osteoporosis, still
160410 - relatively mild. Her mother died at age 86 with severe
160411 - osteroporsis. Older sister died a few years ago from lung cancer.
160412 - Younger sister died of heart failure about 5 years ago. No known
160413 - family history of achalasia. Mother's digestion issues treated
160414 - with over-the-counter medications, which have not been effective
160415 - treating the current problem.
160417 - ..
160418 - Uncle Roy (father's brother) reportedly died of extreme gastric
160419 - distress, about 10 years ago. He was in the VA at Yountville.
160420 - During the meeting today, the doctor did a search for VA records
160421 - on Uncle Roy, and could not find anything.
160423 - ..
160424 - Current problem has worsened over 5 - 10 years. Difficult to
160425 - retain food; requires prolonged meals. Eating normally causes
160426 - vomiting.
160427 -
160428 - [On 100305 1000 VA medical chart reports swallowing problem
160429 - began 20 years ago. ref SDS 30 IH6L
160431 - ..
160432 - Reviewed prior meetings on....
160433 -
160434 - WBC elevated......................... 050816 0830, ref SDS 21 G540
160435 -
160436 - WBC elevaeted after antibiotics...... 050906 1204, ref SDS 24 DG8G
160437 -
160438 - Hiatal hernia discussion............. 050629, ref SDS 16 I597
160440 - ..
160441 - Barium sulfate imaging test
160442 - identified hiatal hernia, and
160443 - a constriction preventing food
160444 - from falling to bottom of
160445 - stomach.............................. 050714, ref SDS 18 Q869
160446 - pylorus and duodenum identified
160447 - as constricted preventing normal
160448 - digestion............................ 050714, ref SDS 18 WE50
160450 - ..
160451 - Achalasia identified as likely
160452 - diagnosis............................ 050816, ref SDS 21 DG97
160453 - referral to GI clinic................ 050816, ref SDS 21 0G7M
160455 - ..
160456 - Report received for test on 050714
160457 - using barium sulfate to assess
160458 - digestion problem.................... 050830, ref SDS 23 UR3M
160459 - and describing esophageal
160460 - constriction......................... 050830, ref SDS 23 6G7I
160461 - consistent with achalasia............ 050830, ref SDS 23 6H9S
160462 -
160463 -
160464 -
160465 -
1605 -
SUBJECTS
Symptoms Achalasia Immediate Bubbling Overflow Sometimes Strong Forc
Family History Digestion Problems No Knowledge on History of Achalas
2304 -
230501 - ..
230502 - Symptoms Immediate Overflow Sometimes Strong Forceful Discharge
230503 -
230504 - The doctor followed up today a referral on 050816 by the primary care
230505 - physician to investigate digestion problem. ref SDS 21 0G7M
230507 - ..
230508 - The doctor asked about the character of vomiting; whether this is a
230509 - gradual bubbling up, or a violent discharge from the stomach?
230511 - ..
230512 - In this case, both forms occur, beginning with gradual bubbling up,
230513 - and on occasion followed by more violent discharge.
230515 - ..
230516 - The doctor noted persistent elevated WBC even after treatment with
230517 - antibiotics, prescribed on 050818 1452. ref SDS 22 OR4G
230518 -
230519 -
230520 -
230521 -
230522 -
230523 -
230524 -
2306 -
SUBJECTS
Achalasia Diagnosed Imaging Shows Dilated Esophagus Rare Affliction
3503 -
350401 - ..
350402 - Achalasia Diagnosed Imaging Shows Dilated Esophagus Rare Affliction
350403 - Gastroesophageal Junction Blocking Discharge into Stomach Achalasia
350404 - Esophagus Sphincter Valve Constricted Dilated Esophagus Achalasia
350405 -
350406 - Follow up ref SDS 21 DG8G.
350407 -
350408 - The doctor showed images on his computer taken during CT tests on
350409 - 050714. He pointed to an enlarged dilated bulge of the esophagus and
350410 - explained this is caused by failure of the lower esophageal sphincter
350411 - valve (LESV) at the gastroesophageal junction to enable discharge of
350412 - swallowed content into the stomach, as shown previously in the record
350413 - on 050714 1000. ref SDS 18 B94J
350414 -
350415 - [On 130117 0900 barium swallow CT test shows significant
350416 - improvement compared to original condition on 050714,
350417 - ref SDS 18 B94J - there is no big bulge and no long
350418 - string-like structure preventing content from flowing into
350419 - the stomach. ref SDS 31 OH6G
350421 - ..
350422 - Doctor Lee advised that the esophagus is a long tube of continuous
350423 - muscle. Swallowing occurs from pulsing muscle contractions that
350424 - propell content along the esophagus and squeeze through the lower
350425 - esphageal sphincter valve (LESV) into the stomach. However, in this
350426 - case, the LESV is not opening enough for normal flow into the stomach,
350427 - causing a backup into a large bulge shown in imaging from radiology
350428 - testing on 050714 1000. ref SDS 18 B94J Continued failure of
350429 - swallowing causes esophagus muscles to atrophy, which diminishes
350430 - ability to pulse which further causes swallowing to fail. (see
350431 - research, ref SDS 0 2T56)
350433 - ..
350434 - This explanation is very similar to the presentation on 050714 that
350435 - described a problem at the bottom of the stomach relating to the
350436 - pylorus and duodenum. ref SDS 18 WE50 In particular it conflicts with
350437 - the explanation that a bulge in the esophagus was not observed.
350438 - ref SDS 18 WE46 The image seen today aligns with the definition of
350439 - achalasia found on 050816 that describes...
350440 -
350441 - ...failure of esophageal sphincter relaxation due to loss of
350442 - myenteric plexus. "Bird Beak" barium swallow; incur risk of
350443 - esophageal cancer; assoc. w/ Chagas disease. ref SDS 21 S69O
350444 -
350445 -
350446 -
350447 -
3505 -
SUBJECTS
Achalasia Rare .4 - 1.2% of Population Esophagus Massively Dilated R
3803 -
380401 - ..
380402 - Achalasia Rare .4 - 1.2% of Population Esophagus Massively Dilated
380403 - Research Achalasia Yields Diagnosis Primary Not Secondary Affliction
380404 - Primary Achalasia Diagnosed No Underlying Cause Symptoms Over Years
380405 - Secondary Achalasia Caused by Cancer Symptoms Manifest in Few Months
380406 -
380407 - The doctor explained that secondary achalasia can be caused by a
380408 - parasite common to Central and South America, shown by research on
380409 - 050714. ref SDS 21 ME4G Research today further indicates that
380410 - secondary achalasia, also, occurs with underlying disease, including
380411 - cancer, ref SDS 0 NH38, and manifests symptoms in a few months.
380412 - ref SDS 0 RB5K
380414 - ..
380415 - The doctor reviewed blood tests on the VA computer, and commented
380416 - there is no evidence of cancer so far. Since there has been no loss
380417 - of weight, and the problem is long-standing, this profile fits
380418 - criteria for primary achalasia, and aligns with analysis of imaging
380419 - received on 050830. ref SDS 23 6H9S
380421 - ..
380422 - He seemed to say that persistent elevated WBC can occur from low grade
380423 - infections because food remains trapped in the throat for long
380424 - periods, per patient history above. ref SDS 0 0V3G
380425 -
380426 - [On 140827 1413 persistent elevated WBC occurred again last
380427 - month or so 6 month period between treatment for achalasia
380428 - with EGD dilation and triamcinolone steriod injections.
380429 - ref SDS 32 YI5F
380431 - ..
380432 - The doctor seemed to indicate that primary achalasia is a rare
380433 - condition.
380435 - ..
380436 - Research indicates...
380437 -
380438 - The Cleveland Clinic
380439 - Motor Disorders of the Esophagus
380440 - Edgar Achkar, MD
380441 - Reviewed 050119
380442 -
380443 - http://www.clevelandclinicmeded.com/diseasemanagement/gastro/motor/motor.htm
380445 - ..
380446 - The annual incidence of achalasia is estimated at 0.4 -1.2 in
380447 - the Western world.
380449 - ..
380450 - Another source says...
380451 -
380452 - NCBI
380453 - Pubmed
380454 - National Library of Medicine and National Institutes of Health
380455 - 901085
380456 - RW Rozman Jr., E Achkar
380457 -
380458 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2220723&dopt=Citation
380460 - ..
380461 - Eighteen patients with cancer-induced or secondary achalasia
380462 - (SA) were compared to 421 patients with idiopathic or primary
380463 - achalasia (PA). The aim of the study was to detect any
380464 - differences in clinical presentation between the two groups.
380465 - Mean age of patients with SA was 57.1 (range 15-78) and 47.1
380466 - (range 1-90) in patients with PA (p = 0.02). Three patients
380467 - with SA were 15, 24, and 36 yr old, respectively. Symptom
380468 - frequency was comparable in SA versus PA.
380470 - ..
380471 - Mean duration of symptoms in SA was 4.5 months, with 15 of the
380472 - 18 patients experiencing symptoms for six months or less.
380473 - Weight loss occurred in 88.2% of patients with SA and 57.3% of
380474 - patients with PA (p less than 0.05). Cancer was at the
380475 - gastroesophageal junction in 16 patients, duodenum in one, and
380476 - breast in one. Endoscopy showed tumor in 12 (67%). The
380477 - esophagram was suspicious for tumor in only 25%. We conclude
380478 - that patients with SA are older, more likely to lose weight,
380479 - and have a short duration of symptoms. However, SA may occur
380480 - in younger patients, and endoscopy with biopsy is necessary in
380481 - any newly diagnosed case of achalasia.
380483 - ..
380484 - Another sources says...
380485 -
380486 - Medpix Disease Topic 1651
380487 - Contributor: Marc S. Levine, MD
380488 - Prepared by Gastrointestinal Learning File - c ACR - ACR Learning Filer - ||
380489 - Peer Review/Approval: James G. Smirniotopoulos, M.D. - Uniformed Services University
380491 - ..
380492 - Primary achalasia
380493 - Factoid 1651 - Created: 2001-04-02 15:09:08-04 - Modified: 2004-06-15 20:46:13-04
380494 -
380495 - http://rad.usuhs.mil/medpix/medpix.html?mode=single&comebackto=mode%3Dcat_browse&recnum=1651
380497 - ..
380498 - Achalasia is a motor disorder of the esophagus characterized
380499 - by absent peristalsis in the esophagus and impaired relaxation
380500 - of the lower esophageal sphincter.
380502 - ..
380503 - The condition is described as primary achalasia when there is
380504 - no underlying disease or as
380506 - ..
380507 - secondary achalasia when it is caused by other abnormalities
380508 - involving the gastroesophageal junction, particularly
380509 - metastatic tumor. In primary achalasia, barium studies
380510 - typically reveal smooth, tapered narrowing of the distal
380511 - esophagus, producing a beak-like configuration at or near the
380512 - gastroesophageal junction (Films .1 and .2). In early disease,
380513 - the esophagus may not be significantly dilated (Film .1). With
380514 - long-standing disease, however, the esophagus can become
380515 - massively dilated and assume a sigmoid configuration above the
380516 - narrowed sphincter segment (Film .2 - note surgical clips from
380517 - unsuccessful Heller myotomy).
380519 - ..
380520 - Squamous cell carcinoma of the esophagus is a well-recognized
380521 - complication of long-standing achalasia. These tumors usually
380522 - appear radiographically as bulky intraluminal masses in the
380523 - dilated esophagus well above the narrowed segment.
380524 -
380525 -
380526 -
380527 -
3806 -
SUBJECTS
Myenteric Plexus Achalasia Disease of the Esophagus Peristalsis Decr
4103 -
410401 - ..
410402 - Myenteric Plexus Achalasia Disease of the Esophagus
410403 - Achalasia Disease of Myenteric Plexus in the Esophagus
410404 - Peristalsis Decreased or Absent Lower Esophageal sphincter Fails Relax
410405 -
410406 - A complete data base at...
410407 -
410408 - http://rad.usuhs.mil/medpix/?mode=tsearch3&srchstr=Achalasia&srch_type=any
410409 -
410410 - 020426 1224
410412 - ..
410413 - Achalasia is a disease of the myenteric plexus of the esophagus
410414 - where the peristalsis is decreased or absent and the lower
410415 - esophageal sphincter fails to relax. Primary or idiopathic
410416 - achalasia usually has its onset in early adulthood and results
410417 - in dysphagia, regurgitation, and other complications of
410418 - esophageal stasis including bad breath, aspiration pneumonia,
410419 - and esophageal candidiasis.
410421 - ..
410422 - 040715 02:25
410424 - ..
410425 - Clinical symptoms include dysphagia, foul breath,
410426 - regurgitation and/or aspiration. The condition is usually
410427 - insidious, developing between age 30-50, and is likely due to
410428 - a defect in esophageal innervation, with impairment or absence
410429 - of ganglion cells in Auerbach*s Plexus. Radiographically,
410430 - abnormal peristalsis (often completely absent) and abnormal
410431 - LES opening are seen with barium swallows.
410433 - ..
410434 - Auerbach's Plexua is researched below. ref SDS 0 3D7H
410436 - ..
410437 - Research Achalasia continues...
410438 -
410439 - Achalasia is a motor disorder of the esophageal smooth muscle,
410440 - characterized by partial or incomplete relaxation of the lower
410441 - esophageal sphincter (LES) with swallowing, abnormal
410442 - esophageal peristalsis, and increased resting tone of the LES.
410443 - The underlying abnormality of primary achalasia involves the
410444 - loss of intramural neurons of Auerbach*s plexus in the smooth
410445 - muscle portion of the esophagus an
410447 - ..
410448 - 051107 2014
410449 -
410450 - http://rad.usuhs.mil/medpix/index.html?mode=single&recnum=6836&srchstr=achalasia&search=achalasia#top
410452 - ..
410453 - Achalasia is a functional obstruction of the distal esophagus
410454 - with resultant proximal dilation. Incomplete relaxation of the
410455 - lower esophageal sphincter is coupled with abnormal
410456 - peristalsis. In its primary form, achalasia is caused by an
410457 - absence or paucity of the ganglion cells of Auerbach's plexus
410458 - which innervates the smooth muscle of the esophagus. Other
410459 - secondary causes include central / peri
410461 - ..
410462 - peristalsis -- wavelike muscular contractions of the alimentary
410463 - canal or other tubular structures by which contents are forced
410464 - onward toward the opening.
410466 - ..
410467 - 051114 1957
410468 -
410469 - http://rad.usuhs.mil/medpix/index.html?mode=single&recnum=5312&srchstr=achalasia&search=achalasia#top
410471 - ..
410472 - Achalasia is a functional obstruction of the distal esophagus
410473 - with consequent proximal dilitation. It is caused by
410474 - incomplete relaxation of the lower esophageal sphincter
410475 - combined with a failure of normal peristalsis. The lower
410476 - esophageal sphincter fails to relax because of degeneration of
410477 - ganglion cells in Auerbach*s (myenteric) plexus. The sphincter
410478 - relaxes only when the hydrostatic pressure
410480 - ..
410481 - 140720 0549
410483 - ..
410484 - The Free Dictionary
410486 - ..
410487 - Achalasia
410488 -
410489 - http://medical-dictionary.thefreedictionary.com/Achalasia+of+the+Cardia
410491 - ..
410492 - Achalasia is a disorder of the esophagus that prevents normal
410493 - swallowing.
410495 - ..
410496 - Achalasia affects the esophagus, the tube that carries
410497 - swallowed food from the back of the throat down into the
410498 - stomach. A ring of muscle called the lower esophageal
410499 - sphincter encircles the esophagus just above the entrance to
410500 - the stomach. This sphincter muscle is normally contracted to
410501 - close the esophagus. When the sphincter is closed, the
410502 - contents of the stomach cannot flow back into the esophagus.
410503 - Backward flow of stomach contents (reflux) can irritate and
410504 - inflame the esophagus, causing symptoms such as heartburn. The
410505 - act of swallowing causes a wave of esophageal contraction
410506 - called peristalsis. Peristalsis pushes food along the
410507 - esophagus. Normally, peristalsis causes the esophageal
410508 - sphincter to relax and allow food into the stomach. In
410509 - achalasia, which means "failure to relax," the esophageal
410510 - sphincter remains contracted. Normal peristalsis is
410511 - interrupted and food cannot enter the stomach.
410513 - ..
410514 - Achalasia is caused by degeneration of the nerve cells that
410515 - normally signal the brain to relax the esophageal sphincter.
410516 - The ultimate cause of this degeneration is unknown. Autoimmune
410517 - disease or hidden infection is suspected.
410519 - ..
410520 - Description of "nerve cells that normally signal the brain" may
410521 - relate to other articles describing...
410522 -
410523 - "...a defect in esophageal innervation, with impairment or
410524 - absence of ganglion cells in Auerbach*s Plexus." shown above.
410525 - ref SDS 0 2T44
410527 - ..
410528 - Wikipedia
410530 - ..
410531 - Auerbach's plexus
410532 -
410533 - http://en.wikipedia.org/wiki/Auerbach's_plexus
410535 - ..
410536 - Auerbach's plexus (or myenteric plexus) provides motor
410537 - innervation to both layers of the muscular layer, having both
410538 - parasympathetic and sympathetic input, whereas Meissner's
410539 - plexus has only parasympathetic fibers and provides
410540 - secretomotor innervation to the mucosa nearest the lumen of
410541 - the gut.
410543 - ..
410544 - It arises from cells in the vagal trigone also known as the
410545 - nucleus ala cinerea, the parasympathetic nucleus of origin for
410546 - the tenth cranial nerve (vagus nerve), located in the medulla
410547 - oblongata. The fibers are carried by both the anterior and
410548 - posterior vagal nerves. The myenteric plexus is the major
410549 - nerve supply to the gastrointestinal tract and controls GI
410550 - tract motility
410551 -
410552 -
410553 -
410554 -
4106 -
SUBJECTS
Treatment Plan Primary Achalasia Pneumatic Dilation with Balloon Ana
4403 -
440401 - ..
440402 - Surgical Myotomy Used Where Pneumatic Balloon Dilation Fails
440403 - Treatment Plan Primary Achalasia Pneumatic Dilation with Balloon
440404 - Analysis Research Compare Patient Symptoms Diagnosis Primary Achalasia
440405 -
440406 - This research indicates secondary achalasia is associated with cancer,
440407 - ref SDS 0 NG9N and ref SDS 0 RC50, and typically takes a few months
440408 - for symptoms to occur, including weight loss, ref SDS 0 RB5K
440410 - ..
440411 - Primary achalasia has no underlying disease, ref SDS 0 RC4L, and takes
440412 - many months or years for symptoms to appear. There is no abrupt loss
440413 - of weight and the esophagus gradually dilates into a distorted sigmoid
440414 - shape. One authority describes the problem may be caused by a
440415 - "...defect in esophageal innervation, with impairment or absence of
440416 - ganglion cells in Auerbach*s Plexus." ref SDS 0 2T44
440418 - ..
440419 - Images presented today from tests on 050714, show conditions of
440420 - long-standing primary achalasia, where the esophagus is massively
440421 - dilated with a sigmoid configuration above the narrowed sphincter
440422 - segment. ref SDS 0 5B5K
440424 - ..
440425 - The doctor explained treatment forces a probe down the throat into the
440426 - constricted esophageal sphincter valve and expands a small balloon to
440427 - dilate the opening. This procedure is repeated twice more with
440428 - slightly larger balloons (see research, ref SDS 0 I342), with the aim
440429 - of rupturing esophogeal muscle fibers (see research, ref SDS 0 9R78),
440430 - and thereby restoring relaxation to the valve that permits food to
440431 - flow more normally into the stomach.
440433 - ..
440434 - A surgical myotomy solution may be used where balloon dilation fails.
440435 - ref SDS 0 N188 and ref SDS 0 N24Y Common failure of pneumatic
440436 - procedure that required correction with surgery is excessive
440437 - perforation. ref SDS 0 S54M
440439 - ..
440440 - The doctor indicated having successful experience performing this
440441 - procedure, and feels this can be an effective treatment in this case.
440442 - Research shows that experience is a critical risk factor for pneumatic
440443 - dilation, and surgical solutions. ref SDS 0 N26F and ref SDS 0 S65N
440444 -
440445 -
440446 -
440447 -
4405 -
SUBJECTS
Due Diligence Experience Physician Reduces Risk Esophageal Damage Pe
4903 -
490401 - ..
490402 - Radiologic Study Immediately after Procedure to Rule Out Perforation
490403 - Experience Reduces Risk Esophageal Damage Pneumatic Dilation Treatment
490404 - Esophageal Perforation Risk Pneumatic Dilation Requires Experience
490405 - Remission Rates Alternate Treatments Pharmacologic Dilation Surgery
490406 -
490407 - Research found three (3) methods of treatment: pneumatic dilation had
490408 - a 90% success rate with remission lasting 5 years on a small study,
490409 - while a competing pharmacologic treatment had a 40% success rate.
490410 - Surgical Myotomy seems to offer the highest success rate, but requires
490411 - expertise from experience performing a rare procedure (see below,
490412 - ref SDS 0 N24Y)....
490413 -
490414 - NCBI
490415 - Pubmed
490416 - National Library of Medicine and National Institutes of Health
490417 - 030303
490418 - Bansal R, Nostrant TT, Scheiman JM, Koshy S, Barnett JL, Elta
490419 - GH, Chey WD
490421 - ..
490422 - Intrasphincteric botulinum toxin versus pneumatic balloon
490423 - dilation for treatment of primary achalasia.
490424 -
490425 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12590230&dopt=Abstract
490427 - ..
490428 - University of Michigan Medical Center, Division of
490429 - Gastroenterology, Ann Arbor, Michigan 48109, USA.
490431 - ..
490432 - GOALS: Despite a high success rate, pneumatic dilatation for
490433 - achalasia is accompanied by a significant risk of esophageal
490434 - perforation.
490436 - ..
490437 - Injection of botulinum toxin (botox) into the lower esophageal
490438 - sphincter (LES) can lead to improvement in symptoms with
490439 - reduced risk of complications. Direct comparisons of the two
490440 - techniques are needed to define their role in clinical
490441 - management. STUDY: We compared pneumatic dilatation to botox
490442 - for patients with achalasia using a double blind, randomized
490443 - study design.
490445 - ..
490446 - Patients underwent clinical, manometric, radiographic and
490447 - endoscopic evaluation to confirm primary achalasia. They were
490448 - randomized to receive either 80 units of botox into the LES or
490449 - Witzel balloon dilatation. Patients also received sham
490450 - dilatation or injection, respectively. The patients and
490451 - investigators assessing symptom response were blinded to
490452 - therapy. Symptoms and esophageal function were assessed at 3
490453 - weeks, 3 months and 1 year after therapy. Treatment failure
490454 - was defined as the lack of decrease in symptom grade more than
490455 - 1 or recurrence of symptoms. Patients with treatment failure
490456 - crossed over to the alternative treatment. RESULTS: Thirty
490457 - four patients were studied, and 31 completed the trial. Of the
490458 - 18 patients randomized to Witzel dilatation, 16 (89%) of 18
490459 - remained in clinical remission. Of the two patients with
490460 - treatment failure, one responded to botox injection. Of the 16
490461 - patients randomized to botox, (38%) 6 of 16 remained in
490462 - clinical remission. Four patients had initial failure, and 6
490463 - relapsed at a mean of 4 months after therapy.
490465 - ..
490466 - Of the nine patients who crossed over to dilatation, seven
490467 - responded well, but two required surgical management of
490468 - perforation. Although both treatments had excellent initial
490469 - clinical improvement, patients randomized to Witzel dilatation
490470 - had superior long-term success...
490472 - ..
490473 - CONCLUSION: Initial therapy with Witzel dilatation is
490474 - associated with better long-term outcome than a single
490475 - injection of botox. Because of the risk of endoscopic
490476 - perforation, botox remains a viable alternative to dilatation.
490478 - ..
490479 - Another source on balloon dilation says in part...
490480 -
490481 - Medscape
490482 - Management of Achalasia
490483 - Peter N. Meier, MD
490484 -
490485 - http://www.medscape.com/viewarticle/420090
490487 - ..
490488 - Invasive Procedures
490490 - ..
490491 - Pneumatic dilatation, with the aim of rupturing the muscle
490492 - fibers, is the most common and effective method for treating
490493 - achalasia.
490495 - ..
490496 - A prospective study on single dilatation revealed a long-term
490497 - effect maintained after 5 years in 30% to 40% of patients.[4]
490498 - When this group of patients was stratified by age, the clinical
490499 - results for those over 40 were clearly better than those for
490500 - the younger patients. Therefore, this therapy is not
490501 - recommended for children and juveniles. However, there are no
490502 - data on the prevention of complications, and therapeutic
490503 - efficacy can only be assessed by symptomatic or functional
490504 - improvement.
490506 - ..
490507 - An analysis of pneumatic dilatation found that a postdilation
490508 - LES pressure greater than 10 mm Hg was the best predictor of
490509 - prolonged remission; patients with values greater than 20 mm Hg
490510 - had little benefit. Effective dilatation therapy shows a 5%
490511 - risk factor for perforation and other life-threatening events.
490513 - ..
490514 - However, the risk of complications depends largely on the
490515 - experience of the center, because the frequency of
490516 - complications decreases with increasing number of interventions
490517 - performed. It is therefore recommended that pneumatic
490518 - dilatations be performed in centers experienced in this method.
490519 - Other complications include chest pain, intramural hematoma,
490520 - and traumatic epiphrenic diverticula, which probably represent
490521 - expression of incomplete perforations.
490523 - ..
490524 - In comparison to pneumatic dilatation, the aim of surgical
490525 - myotomy is the total disruption of function under distinctly
490526 - advantageous conditions. Disadvantages to this approach
490527 - include surgical requirements, such as anesthesia and
490528 - laparotomy, as well as the frequent occurrence of postoperative
490529 - reflux.
490531 - ..
490532 - Doctor Edgar Achkar analysis cited above, ref SDS 0 NG9N, says in
490533 - part...
490534 -
490535 - The procedure is carried out with sedation and under
490536 - fluoroscopy so the balloon is positioned at the level of the
490537 - diaphragm.
490539 - ..
490540 - The balloon is inflated until the waist at the gastroesophageal
490541 - junction disappears. The duration of the distention varies
490542 - from report to report but an inflation of 30 seconds is
490543 - reasonable. The patient experiences some chest pain and, upon
490544 - withdrawal of the device, blood streaks are often seen on the
490545 - balloon.
490547 - ..
490548 - There is a 2 to 6% risk of perforation. This is why a
490549 - radiologic study is obtained immediately after the procedure to
490550 - rule out perforation which, if present, would require
490551 - thoracotomy and surgical repair. The procedure is successful
490552 - in 65 to 90% of patients.
490554 - ..
490555 - The technique of graded dilation has been advocated starting
490556 - with a smaller balloon size of 3 cm and repeating the
490557 - procedure with larger balloons at later dates. This method is
490558 - accompanied by a lower initial success rate but seems to
490559 - reduce the number of complications.
490561 - ..
490562 - Surgical Myotomy:
490564 - ..
490565 - Surgical myotomy or Heller's myotomy, named for the German
490566 - surgeon who performed it first in 1914, aims at releasing LES
490567 - pressure by performing a longitudinal muscular incision which
490568 - extends above the esophagogastric junction but not too far
490569 - distally to avoid acid reflux. There are very few studies
490570 - comparing pneumatic dilation and Heller's myotomy for the
490571 - treatment of achalasia.11,12 Myotomy appears more successful
490572 - than pneumatic dilation with success rates of 85% to 95%.
490574 - ..
490575 - The advent of laparoscopic myotomy, resulting in less morbidity
490576 - and a shorter hospital stay, has made the procedure much more
490577 - attractive as initial treatment option. The choice between
490578 - pneumatic dilation and surgical myotomy should be made by the
490579 - patient with the assistance of his or her physician. The
490580 - patient should be treated in an institution that offers
490581 - expertise in both procedures. Failure of pneumatic dilation
490582 - does not preclude surgical treatment. Some patients have
490583 - undergone pneumatic dilation after surgery as well. The
490584 - Society for Surgery of the Alimentary Tract (SSAT) has
490585 - published a guideline on the surgical treatment of achalasia.
490586 - The recommendations are vague and the required qualifications
490587 - to perform such surgery are based on board certification and
490588 - eligibility and "training and experience
490589 -
490590 -
490591 -
490592 -
4906 -
SUBJECTS
Endoscopy Schedule 041207 Verify Scope of Problem Testing Verify Pri
6203 -
620401 - ..
620402 - Schedule Endoscopy 041207 Verify Scope of Problem
620403 - Endoscopy Test Verify Primary and Not Secondary Achalasia
620404 - Due Diligence Verify Achalasia Scope Schedule Endoscopy 041207
620405 -
620406 - Follow up ref SDS 21 0G7M.
620407 -
620408 - To prepare for treatment, the doctor first proposes testing to verify
620409 - there is no cancer or other complication. This fits the model for
620410 - clinical, manometric, radiographic and endoscopic evaluation found in
620411 - research to confirm primary achalasia. ref SDS 0 S58L This is done
620412 - with endoscopy imaging. The patient is anesthetized, and so needs a
620413 - driver for outpatient transportation home after the procedure.
620415 - ..
620416 - The doctor scheduled the endoscopy work for next Friday, 051207 1130,
620417 - and the nurse, Gloria, issued pre-procedure instructions...
620418 -
620419 - [On 051209 endoscopy examination preliminary findings no evidence
620420 - of cancer, ref SDS 29 0001; biopsy report should be submitted in a
620421 - few weeks to confirm status of cancer, ref SDS 29 PY5J, and if so,
620422 - then a procedure can be schedule for next month to dilate the
620423 - exophageal sphincter valve. ref SDS 29 NZ5H
620424 -
620426 - ..
620427 - Endoscopy Instructions to Prepare for Procedure
620428 -
620429 -
620430 - VANCHC'S - Martinez
620431 - PRE-ESOPHAGOGASTRODUDENOSCOPY (EGD)
620432 - Patient Instructions
620433 -
620434 - 1. Procedure date: Friday 051209......... Time: 1130
620436 - ..
620437 - 2. No aspirin or any medications containing aspirin for 7 days
620438 - prior to your procedure, starting 051202,
620440 - ..
620441 - 3. No arthiritic medicines, such as [shown on back of sheet...]
620442 - for 48 hours starting 051207.
620444 - ..
620445 - 4. If your test is scheduled for the morning, please do not eat or
620446 - drink, after midnight.* If your test is scheduled after 1:00
620447 - PM, you may have clear liquids (i.e., apple juice, tea, or
620448 - black coffee) before 0700 AM.
620449 -
620450 - * liquid diet for 48 hours, starting 051207.
620452 - ..
620453 - 5. If you are diabetic, do not take your diabetic pill or insulin
620454 - on the day of the procedure. Please bring them with you.
620456 - ..
620457 - 6. You are to report to Reception C on the Second Floor. Please
620458 - present your driver to the Medical clerk at this time.
620460 - ..
620461 - 7. Someone must take you home. You will be medicated for this
620462 - procedure, therefore, you cannot operate a motor vehicle for
620463 - 24 hours after your procedure.
620465 - ..
620466 - 8. EGD pamphlet and NSAIDS list given. RW [patient initials]
620468 - ..
620469 - 9. If you have any questions, please call 925 372 2000 ext 5168
620470 - or 925 372 2762, preferably in the afternoon.
620471 -
620473 - ..
620474 - 10. Nurse's Signature Date:
620475 -
620477 - ..
620478 - 11. These instructions have been explained to me. I understand my
620479 - responsibility to follow them and have received a copy.
620480 -
620482 - ..
620483 - 12. Date: 051202 Time: 1600
620484 -
620486 - ..
620487 - Patient's & or Significant Other's Signature
620488 -
620490 - ..
620491 - 13. Imprint Patient's Data Card
620492 - Name Address Social Security Number
620493 -
620495 - ..
620496 - Medical Record Nursing Documentation
620497 -
620499 - ..
620500 - 612 Form 0454
620501 - October 1999
620502 - US Government Printing Office 2004-684-921
620503 -
620504 -
620505 -
620506 -
6206 -
SUBJECTS
Endoscopy Explanation Preparations Risk Management Due Diligence
7103 -
710401 - ..
710402 - Endoscopy Explanation Preparations and Risks
710403 -
710404 - Part of the documentation received from Gloria is a document that
710405 - says...
710406 -
710407 - 1. What is EGD?
710408 -
710409 - a. A panenduscope is a long flexible tube that is thinner than
710410 - most food you swallow. It is passed through the mouth and
710411 - back of the throat into the upper digestive tract and
710412 - allows the physician to examine the lining of the
710413 - esophagus, stomach, and duodenum (the first portion of the
710414 - small intestine).
710416 - ..
710417 - b. Abnormalities suspected by X-ray can be confirmed and
710418 - others may be detected which are too small to be seen on
710419 - X-ray. If the doctor sees a suspicious area, he can pass
710420 - an instrument through the endoscope and take a small piece
710421 - of tissue (a biopsy) for examination in the laboratory.
710422 - Biopsies are taken for many reasons and do not necessarily
710423 - imply cancer.
710425 - ..
710426 - c. Other instruments can also be passed through the endoscope
710427 - without causing discomfort, including a small brush to wide
710428 - cells from a suspicious area for examination in the
710429 - laboratory (a form of pap test or "cytology") and a wire
710430 - loop or snare to remove polyps (abnormal, usually benign,
710431 - growths of tissue)
710433 - ..
710434 - 2. What Preparation is Required?
710435 -
710436 - a. For the best possible examination, the stomach must be
710437 - completely empty, so you should have nothing to eat or
710438 - drink, including water from 11 PM the evening before the
710439 - examination or for at least six hours before its
710440 - performance. You doctor will be more specific about the
710441 - tie to begin fasting, depending on the time of the day that
710442 - your EGD is scheduled.
710444 - ..
710445 - b. Be sure to let your doctor know if you are allergic to any
710446 - drugs.
710448 - ..
710449 - c. A companion must accompany you to the examination because
710450 - will given medication to help you relax. It will make you
710451 - drowsy. So you will not be allowed to drive after the
710452 - procedure. Even though you may not feel tired, your
710453 - judgement and reflexes may not be normal.
710455 - ..
710456 - d. Please bring your Xrays with you, as they may be important.
710457 -
710459 - ..
710460 - 3. What Should You Expect from the Procedure?
710461 -
710462 - a. Your doctor will give you medications through a vein to
710463 - make you relaxed and sleepy, and your throat may be sprayed
710464 - with local anesthetic. While you are in a comfortable
710465 - position, the panedoscope is inserted through the mouth,
710466 - and each part of the esophagus, stomach, and duodenum is
710467 - examined.
710469 - ..
710470 - b. The procedure is extremely well tolerated with little or no
710471 - discomfort. Many patients even fall asleep during EGD.
710473 - ..
710474 - c. The tube will not interfere with your breathing. Gagging
710475 - is usually prevented by the medication.
710476 -
710478 - ..
710479 - 4. What Happens After the EGD?
710480 -
710481 - a. You will be kept in the endoscopic area until most of the
710482 - effects of the medication have worn off. You throat may be
710483 - a little soar for a couple of hours and you may feel
710484 - bloated for a few minutes right after the procedure because
710485 - of the air that was introduced to examine your stomach.
710487 - ..
710488 - b. You will able to resume your diet after the EGD unless you
710489 - are instructed otherwise.
710491 - ..
710492 - 5. Are There Any Complications from EGD?
710493 -
710494 - a. EGD is safe and is associated with very low risk when
710495 - performed by physicians who have been specially trained and
710496 - are experienced in this endscopic procedure. Complications
710497 - can occur but are rare.
710499 - ..
710500 - b. One possible complication is perforation in which a tear
710501 - through the wall of the esophagus or stomach may allow
710502 - leakage of digestive fluids. This complication may be
710503 - managed simply by aspirating the fluids until the opening
710504 - seals, or may require surgery.
710506 - ..
710507 - c. Bleeding may occur from the site of biopsy or polyp
710508 - removal. It is usually minimal but rarely may require
710509 - transfusions or surgery.
710511 - ..
710512 - d. Localized irritation of the vein may occur at the site of
710513 - medication injection. A tender lump develops which may
710514 - remain for several weeks to several months but goes away
710515 - eventually.
710517 - ..
710518 - e. Other risks include drug reactions and complications from
710519 - unrelated diseases such as heart attack or stroke.
710521 - ..
710522 - f. Death is extremely rare, but remains a remove possibility.
710523 -
710524 -
710525 -
710526 -
710527 -
710528 -
7106 -
SUBJECTS
Colonoscopy Planned Following Completion of Treatment for Achalasia
Achalasia Diagnosed Imaging Shows Dilated Esophagus Rare Affliction
7604 -
760501 - ..
760502 - Colonoscopy Examination Planned Following Treatment Achalasia
760503 -
760504 - The doctor asked about colon examination.
760506 - ..
760507 - A sigmoidoscopy was performed on 000208. ref SDS 2 0001 The original
760508 - schedule on 990628 seemed to call for a colonoscopy, ref SDS 1 2099,
760509 - however, the doctor, who did the work, clarified that a sigmoidoscopy
760510 - was actually performed, ref SDS 2 M588, and further indicated that
760511 - this type of test is required every 10 years. ref SDS 2 M636 Later,
760512 - on 010426 a staff nurse at Kaiser indicates standard practice calls
760513 - for this type of examination every five (5) years. ref SDS 5 5X93
760515 - ..
760516 - Research indicates that...
760517 -
760518 - Study Questions Frequency Of Sigmoidoscopy
760519 - Article 030422
760520 - American Cancer Society
760521 -
760522 - http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Study_Questions_Frequency_Of_Sigmoidoscopy.asp
760524 - ..
760525 - Colorectal cancer is the second leading cancer killer in the
760526 - United States. The American Cancer Society estimates that it will
760527 - strike more than 147,000 people this year, and kill some 57,000.
760528 - But colorectal cancer can be detected early -- and even prevented
760529 - - by regular screening. Some screening tests can detect colon
760530 - polyps that could turn cancerous if not removed.
760532 - ..
760533 - The Society's guidelines for the early detection of cancer
760534 - recommend... flexible sigmoidoscopy (a scope inserted into the
760535 - rectum to allow the doctor to see the lower part of the colon)
760536 - every five years. Alternatively, people can get a colonoscopy
760537 - every 10 years, or a double contrast barium enema every five years.
760538 - People with a family history of colon cancer or other risk factors
760539 - should begin screening earlier and get screened more frequently.
760541 - ..
760542 - In the new study, researchers from the Fred Hutchinson Cancer
760543 - Research Center suggested the interval between sigmoidoscopies can
760544 - safely be increased to 10 years. Their findings were published in
760545 - the Journal of the National Cancer Institute (Vol. 95, No. 8:
760546 - 622-625).
760548 - ..
760549 - The researchers noted that other studies have found the benefits
760550 - of sigmoidoscopy last as long as 10 years. And they said polyps
760551 - can take as long as 15 years to turn cancerous.
760553 - ..
760554 - This record supports timely testing proposed today.
760556 - ..
760557 - The doctor advised that the VA currently performs colonoscopy rather
760558 - than sigmoidoscopy, and pointed to a cut-away diagram of the body on
760559 - the examination room wall to show that a colonoscopy is much more
760560 - thorough.
760562 - ..
760563 - This will be scheduled after completing treatment for achalasia.
760565 - ..
760566 - Consideration might be given to requesting results from Kaiser for the
760567 - test on 000208, and then determine if follow up examination is
760568 - required earlier than 10 years, possibly due to intervening and
760569 - worsening achalasia, per above. ref SDS 0 5B5K If the current
760570 - protocol is for testing every five (5) years, then this is a good time
760571 - to do the follow up test, since next year will start a new five (5)
760572 - year period, since the last test on 000208.
760573 -
760574 -
760575 -
760576 -
760577 -
760578 -