Manometry is considered to be the gold standard for the diagnosis of achalasia. However, many physicians believe that contrast radiography, classically showing esophageal dilation with bird-beak narrowing of the gastroesophageal junction, is also accurate in either diagnosing or excluding the disorder. The aim of the current study was to determine the accuracy of barium x-ray in the diagnosis of achalasia. The radiological diagnosis of all patients manometrically diagnosed with achalasia (using conventional criteria) between January 1994 and June 1998 were reviewed. A total of 51 cases of achalasia were identified. Thirteen patients were excluded because they either did not have contrast radiography before a manometric diagnosis or had their x-rays performed more than six months previously. Of the remaining 38 patients, achalasia was stated as a diagnostic possibility in the radiologists report in only 22 (58%) of those patients. Achalasia was not considered in the remaining 16 patients: two were reported as normal, four as having stenosis/narrowing in distal esophagus, two as having presbyesophagus, one as having mild gastroesophageal reflux and seven as having nonspecific dysmotility. To determine the reason for the diagnostic failure of the barium x-ray, an expert gastrointestinal radiologist reviewed 12 of the nondiagnostic x-rays in a blinded fashion, interspersed with 10 randomly selected esophageal-contrast radiographs from control subjects to avoid bias. Of these initially nondiagnostic x-rays in achalasia patients, typical radiological features of achalasia were deemed to be present in 50%. The present study indicates that contrast radiography lacks sensitivity in the diagnosis of achalasia. This is not only due to radiologist oversight but also because of the absence of the characteristic radiological features in many cases. This reinforces the important role of esophageal manometry in patients with persistent nonstructural dysphagia.
With the use of intraluminal manometry in alpha-chloralose-anesthetized opossums, distal esophageal and lower esophageal sphincter responses to prolonged midesophageal balloon distension were compared with those evoked by single transient distensions, vagal efferent stimulation, and swallowing. Balloon inflation caused sphincteric relaxation that recovered during small volume but persisted during large volume-prolonged distension. The esophageal body was either quiescent or exhibited nonperistaltic contractions during prolonged distension. Balloon deflation induced non-peristaltic esophageal and sphincteric contractions as well as further sphincter relaxation. Responses to prolonged large and small volume balloon distension resembled those evoked by high- and low-frequency vagal efferent stimulation, respectively. However, vagal-stimulated "on" contractions were not seen with balloon distension, and atropine did not modify excitatory responses occurring during or after prolonged distension. Although transient distension induced peristaltic esophageal contractions, the peristaltic velocity was faster than swallow-induced peristalsis. With transient distension, atropine prolonged the latency to contraction in the mid but not the distal smooth muscle segment and thus increased peristaltic velocity. These studies demonstrate that 1) esophageal distension evokes a wide spectrum of lower esophageal sphincter and esophageal body response, and 2) cholinergic neurons play a minimal role in distension-induced responses of the distal esophageal circular muscle below the distending balloon.
Long wait times for health care have become a significant issue in Canada. As part of the Canadian Association of Gastroenterology's Human Resource initiative, a questionnaire was developed to survey patients regarding wait times for initial gastroenterology consultation and its impact. A total of 916 patients in six cities from across Canada completed the questionnaire at the time of initial consultation. Self-reported wait times varied widely, with 26.8% of respondents reporting waiting less than two weeks, 52.4% less than one month, 77.1% less than three months, 12.5% reported waiting longer than six months and 3.6% longer than one year. One-third of patients believed their wait time was too long, with 9% rating their wait time as 'far too long'; 96.4% believed that maximal wait time should be less than three months, 78.9% believed it should be less than one month and 40.3% believed it should be less than two weeks. Of those working or attending school, 22.6% reported missing at least one day of work or school because of their symptoms in the month before their appointment, and 9.0% reported missing five or more days in the preceding month. A total of 20.2% of respondents reported being very worried about having a serious disease (ie, scored 6 or higher on 7-point Likert scale), and 17.6% and 14.8%, respectively, reported that their symptoms caused major impairment of social functioning and with the activities of daily living. These data suggest that a significant proportion of Canadians with digestive problems are not satisfied with their wait time for gastroenterology consultation. Furthermore, while awaiting consultation, many patients experience an impaired quality of life because of their gastrointestinal symptoms.
Summary Renal biopsy in the early puerperium was carried out on 20 patients with toxaemia and 13 abruptio placentae without preceding toxaemia. The tissue obtained was studied by light and electron microscopy. All patients had a very similar glomerular lesion with (1) swelling and slight proliferation of the endotheliat cells, (2) increase in the number of mesangial cells and the amount of the mesangial matrix, and (3) granular deposits derived from fibrinogen within the endothelial cells and the mesangial matrix. It is suggested that in both toxaemia and abruptio placentae there is release of thromboplastin from the placental site into the circulation which causes disseminated intravascular coagulation; this process is complicated by the fact than in pregnancy the fibrinolytic mechanism is in any case impaired. The glomerular lesion in both groups is the result of the response of the endothelial cells and mesangium to deposited fibrin or its derivatives.
Summary Two patients are described who had used intrauterine contraceptive devices and developed pelvic actinomycosis with ureteric obstruction.
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