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 -