ARTICLE OF THE WEEK

April 6, 2000

 1.  Which of the following criteria are required for the diagnosis of achalasia

            a.  dilated esophagus on UGIS

            b.  high LES pressure

            c.  lack of peristalsis in the smooth muscle portion of the esophagus

            d.  no LES relaxation on swallowing

            e.  no relaxation or abnormal LES relaxation on swallowing

 2.  The initial test of choice when achalasia is suspected is

            a.  upper endoscopy

            b.  upper GI series

            c.  esophageal manometry

            d.  chest X-ray

            e.  esophageal pH monitoring

 3.  Correct statements regarding the clinical presentation of achalasia include

            a.  chest pain may be a presenting feature in 40% of patients

            b.  significant weight loss is expected with idiopathic achalasia

            c.  heartburn is almost never present

            d.  regurgitation of food or saliva occurs in 75% of patients, particularly while

recumbent.

 True or False

 4.  Esophageal bag dilatation is the treatment of choice for patients with achalasia who are not operative candidates.

 5.  The most common long-term complication of the Heller myotomy is GERD

 6.  Calcium channel blockers and nitrates are recommended for patients with dilated esophagus who did not respond to bag dilation

 7.  Manometry can differentiate achalasia from pseudoachalasia

 8.  Loss of nitric oxide leads to loss of LES relaxation, while the loss of post-inhibitory neurons lead to lack of esophageal peristalsis.

 9.  Botulinum toxin relieves the symptoms of achalasia by inhibiting the calcium-dependent release of acetylcholine from nerve terminals.

 10.  A hiatal hernia on UGIS virtually excludes achalasia as a possible diagnosis.

 11.  A tumor at the GE junction causing pseudoachalsia is easily detected by upper endoscopy

 12.  Success rates for esophageal bag dilation are approximately 50% to 93%, the perforation rate is 2%

 13.  Relaxation of the LES to the gastric baseline on swallowing excludes the diagnosis of achalasia.

 14.  Conditions that increase the risk of perforation when performing a bag dilation include:

            a.  dilated and tortuous esophagus

            b.  previous surgery at the GE junction

            c.  older age

            d.  esophageal diverticuli

            e.  vigorous achalasia

 15.  Regarding therapy of achalasia with botulinum toxin

            a.  short-term efficacy in reducing symptoms is seen in up to 85% of patients

            b.  symptoms tend to recur within 6 months

            c.  older patients and those with vigorous achalasia are less likely to respond

            d.  patients who respond to initial injection will respond to subsequent injections

in a similar fashion.

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