THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: December 2, 2005 02:30 PM Friday;
Rod Welch
VA GI clinic meeting digestion issue diagnosis achalasia, treatment plan.
1...Summary/Objective
2...Meeting Gastrointestinal Department Evaluate Digestion Problem
3...Family History Digestion Problems No Knowledge on History of Achalasia
4...Personal History Digestion Issues and Record Prior Investigations
5...Symptoms Immediate Overflow Sometimes Strong Forceful Discharge
6...Achalasia Diagnosed Imaging Shows Dilated Esophagus Rare Affliction
7...Gastroesophageal Junction Blocking Discharge into Stomach Achalasia
8...Esophagus Sphincter Valve Constricted Dilated Esophagus Achalasia
9...Achalasia Rare .4 - 1.2% of Population Esophagus Massively Dilated
10...Research Achalasia Yields Diagnosis Primary Not Secondary Affliction
11...Primary Achalasia Diagnosed No Underlying Cause Symptoms Over Years
12...Secondary Achalasia Caused by Cancer Symptoms Manifest in Few Months
13...Myenteric Plexus Achalasia Disease of the Esophagus
14...Achalasia Disease of Myenteric Plexus in the Esophagus
15...Peristalsis Decreased or Absent Lower Esophageal sphincter Fails Relax
16...Surgical Myotomy Used Where Pneumatic Balloon Dilation Fails
17...Treatment Plan Primary Achalasia Pneumatic Dilation with Balloon
18...Analysis Research Compare Patient Symptoms Diagnosis Primary Achalasia
19...Radiologic Study Immediately after Procedure to Rule Out Perforation
20...Experience Reduces Risk Esophageal Damage Pneumatic Dilation Treatment
21...Esophageal Perforation Risk Pneumatic Dilation Requires Experience
22...Remission Rates Alternate Treatments Pharmacologic Dilation Surgery
23...Schedule Endoscopy 041207 Verify Scope of Problem
24...Endoscopy Test Verify Primary and Not Secondary Achalasia
25...Due Diligence Verify Achalasia Scope Schedule Endoscopy 041207
26...Endoscopy Instructions to Prepare for Procedure
27...Endoscopy Explanation Preparations and Risks
28...Colonoscopy Examination Planned Following Treatment Achalasia
..............
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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 -