Introduction

Oesophageal achalasia is a motility disorder characterized by the lack of relaxation of the lower oesophageal sphincter and absence of normal oesophageal motility. Among endoscopic techniques to treat achalasia, highlight peroral oesophageal endoscopic miotomy (POEM) and endoscopic balloon dilatation (ED). Some studies demonstrate that ED could achieve similar results to traditional surgical technique (Heller miotomy). However, studies comparing POEM and repeated ED protocols are lacking.

Aims & Methods

Objectives: To compare manometric and clinical data from a group of patients with achalasia treated with a 2-session endoscopic dilatation protocol (EDx2) vs POEM.
Material and Methods: We performed a retrospective review of oesophageal high-resolution manometry (HRM) and clinical records of patients with achalasia treated with EDx2 (30 and 35 mm balloon separated by 2 weeks) or POEM. Only patients with pre and post-treatment HRM were included. Data regarding epidemiological (age, sex), clinical (Eckardt score, complications) and HRM (integrated relaxation pressure, achalasia subtype, rapid drink challenge) were recorded. Technical success was defined as post-treatment IRP < 15 mmHg, clinical success was defined as post-treatment Eckardt score < 3 points, and global success when both conditions were present

Results

Sixty-one patients were included, 32 treated with EDx2 and 29 with POEM. Of those, 67% were type II, 20% type III and 13% type I achalasia. Main baseline characteristics were similar between groups except for a higher baseline Eckardt score in POEM. Both techniques show similar results regarding technical success (69% DB vs 86% POEM, p=ns), clinical success (93 DB vs 93% POEM, p=ns) and overall success (61% DB vs 79% POEM, p=ns). However, when analysing the success according to subgroups of achalasia, we found a trend to greater overall success with POEM in type III achalasia (EDx2 33% vs POEM 100%, p=0.06). No differences were found between both techniques in overall success for type II (68% DB vs 79% POEM, p=ns) and type I (67% DB vs 60% POEM, p=ns) achalasia.

Conclusion

A 2-session endoscopic dilatation protocol achieved therapeutic success similar to POEM in type I and type II achalasia. In type III achalasia, POEM seems superior to endoscopic dilatation.

Clinical Case Summary

We present the case of a 50-year-old man diagnosed with anti-EJ positive anti-synthetase syndrome in 2020. Two years after the diagnosis, he began experiencing subacute episodes of postprandial abdominal pain, distension, and vomiting. On physical examination, the abdomen was distended, non-tender, and tympanic. Abdominal CT revealed dilatation of small bowel loops without evidence of mechanical obstruction. Endoscopic studies ruled out endoluminal lesions. Given the suspicion of a severe gastrointestinal (GI) motility disorder, a comprehensive motility evaluation was performed. Esophageal manometry revealed absent contractility, gastric emptying scintigraphy was consistent with gastroparesis, and small bowel manometry demonstrated absence of normal migrating motor complexes during fasting and a weak postprandial motor response, findings compatible with a myopathic pattern. A diagnosis of chronic intestinal pseudo-obstruction (CIPO) secondary to autoimmune disease activity was established. The patient’s immunosuppressive therapy was escalated to tofacitinib and supportive treatment with prokinetics (prucalopride), non- absorbable antibiotics for small intestinal bacterial overgrowth and nutritional supplementation, was initiated. The patient showed symptomatic improvement during follow-up, although small bowel dilation persisted on imaging studies. CIPO is the most severe form of GI motility disorder, representing the end stage of various conditions affecting the neuromuscular system of the GI tract (1). Autoimmune diseases are recognized causes of CIPO, with connective tissue disorders being the most frequently documented. The treatment of CIPO involves two main approaches: addressing the underlying disease, in this particular case, through immunosuppression, and providing supportive care to maintain adequate nutrition. A high index of suspicion for severe GI motility disorders is essential to avoid delays in diagnosis and to initiate effective treatment promptly.

References

1. Malagelada C and Alcalá-González LG. Mistakes in chronic intestinal pseudoobstruction and how to avoid them. UEG Education 2024; 24: 12-17.
Pictures from abdominal distention crisis, radiological CT images and manometric tracings, including high-resolution jejunal manometry (small bowel) will be presented.

Introduction

The DOMINO diet app (diet) provides superior symptom relief to a spasmolytic agent (otilonium bromide, OB) in primary care Irritable Bowel Syndrome (IBS)¹. While the DOMINO diet aimed to provide a practical approach to lower intake of FODMAPs (fermentable oligo-, di-, monosaccharides and polyols), genetic polymorphisms in the eosinophil trafficking chemokine receptor CCR3 were associated with response to the diet². A correlation between fecal eosinophil-derived neurotoxin (F-EDN) and colonic mucosal eosinophil degranulation was previously reported in IBS³.

Aims & Methods

To assess a role for eosinophil-driven mucosal inflammation as a target for IBS therapy, we assessed changes in F-EDN levels in primary care patients treated with the DOMINO diet and OB, and their correlation with symptoms and inflammatory markers. In the DOMINO study, primary care physician-diagnosed IBS patients (70% fulfilling Rome IV, Rome+) were randomized to diet or OB. Analysis of gene polymorphisms, blood and stool samples were collected from 356 patients (86 IBS-C, 116 IBS-D, and 154 IBS-M) before and after treatment with diet and OB (respectively n=147 and 163). We compared and correlated F-EDN levels, demographic parameters, IBS symptom severity scoring (IBS-SSS), laboratory blood tests as well as biomarkers of inflammation in stool (secretory Ig/sIgA, Beta-defensin2, calprotectin). Statistical analysis was conducted using non-parametric tests; data were presented as median with interquartile range.

Results

Baseline F-EDN correlated negatively with presence of CCR3 polymorphism (r=-0.13, p=0.02), positively with sIgA (r=0.27, p<0.0001), but showed no significant associations with IBS-SSS scores or other stool parameters. Furthermore, a positive correlation was observed between F-EDN and glucose (r=0.16, p=0.004), insulin (r=0.14, p=0.01) and triglyceride (r=0.12, p=0.03) plasma levels and body weight (r=0.16/p=0.002). F-EDN decreased significantly in responders to the diet (≥50-point improvement on IBS-SSS) (n=104, 0.44μg/g[0.16;0.88] vs. 0.32μg/g[0.15;0.72], p=0.03), but not to medication (n=97, 0.48μg/g[0.16;1.01] vs. 0.44μg/g[0.19;0.87], p=0.57). In diet responders, baseline F-EDN levels correlated positively with calprotectin and sIgA (respectively r=0.24, p=0.01 and r=0.37, p<0.001). The significant decrease in F-EDN after diet was more pronounced in the subset of patients fulfilling Rome IV criteria (n=86, 0.47μg/g[0.17;0.91] vs. 0.34μg/g[0.16;0.75], p=0.02). Baseline F-EDN levels in this cohort correlated with the improvement in IBS-SSS (r=0.21, p=0.04).

Conclusion

In primary care IBS, response to the DOMINO diet, but not to OB, is associated with the presence and decrease of eosinophil-driven intestinal immune activation. Further research will focus on the ability of the DOMINO diet, besides its FODMAP-lowering properties, to improve atypical food allergic reactions involved in IBS pathophysiology.

References

1. Carbone, Van den Houte et al. Gut. 2022
2. Balsiger et al. Gut. 2023
3. Casado-Bedmar et al. Journal of Leukocyte Biology. 2022

Clinical Case Summary

A 64-year-old male patient presented with acute epigastric pain over 7 days, worsening after meals, nausea, vomiting 2 times without signs of bleeding, diarrhea 5-6 times/day, high blood pressure 180/100 mmHg. He had a 6-year history of recurrent epigastric pain, after multiple EGDSs was diagnosed as gastric ulcer and atrophic gastritis. The patient had undergone HP eradication and received standard anti-ulcer therapy several times, with no clinical improvement. On physical examination, the patient appeared pale. The abdomen was soft, without pain, guarding or rebound tenderness. The patient's medical history was significant for arterial hypertension. Lab abnormalities included WBC 16.32-10x10⁹/L, ESR 94mm/sec, CRP at 184.3 mg/L, FBG 767 mg, Total protein 50.9 g/L, CREA 147 mmol/L, Urea 13.42 mmol/L, Na 129 mmol/L. Intestinal infections were negative. New EGDS revealed an ulcerative lesion with 0.8cm diameter, in the region from antrum to greater curvature, covered with fibrin. Colonoscopy was normal. Duplex ultrasound revealed a 70% stenosis of the celiac trunk and superior mesenteric artery, with atherosclerotic wall deformation and intima-media thickening. A thrombosis was detected in the region of the aortic bifurcation. CT angiography revealed up to 70% stenosis of the suprarenal abdominal aorta, no contrast enhancement was observed in the origins of the celiac trunk, superior mesenteric artery, left renal artery (left kidney appeared atrophic), total occlusion of bilateral common, external, and internal iliac arteries.
Conclusion: Gastric ulcers are mostly associated with HP. However, in rare cases, underlying vascular pathology may be critical in their pathogenesis. This case highlights an overlooked cause of gastric ulcers, particularly in patients with atherosclerotic risk factors. In patients with persistent symptoms despite medical therapy ischemic ulceration should be included in the differential diagnosis.