Calcium channel blockers have been previously shown to decrease lower esophageal sphincter (LES) pressure and improve symptoms in achalasia. We performed a placebo-controlled, double-blind, crossover study to assess the effects of oral nifedipine and verapamil on LES pressure, amplitude of esophageal body contraction, and clinical symptomatology in eight patients with symptomatic achalasia diagnosed by endoscopy, barium swallow, and manometry. Patients were randomized to receive up to 20 mg nifedipine, 160 mg verapamil, or placebo and underwent esophageal manometry before (baseline) and after four weeks on each drug. Diary cards were kept to record and grade symptoms and drug plasma level determinations were correlated with manometric and clinical findings. Both nifedipine and verapamil caused a statistically significant decrease in mean LES pressure, but only nifedipine caused a significant decrease in the amplitude of contractions of the smooth muscle portion of the esophagus. No statistically significant differences in the overall clinical symptomatology were noted with any of the drugs, although some individual improvements in dysphagia and chest pain were noted. We conclude that, despite the reduction in LES pressure and contraction amplitude of the distal esophageal body, oral nifedipine and verapamil do not significantly alter the clinical symptomatology of patients with achalasia.

A 55-year-old woman presented with several protracted episodes of diarrhea; it was found to be secretory in origin. In the course of evaluating the diarrhea, an ultrasound of the abdomen was performed which disclosed a large right adrenal mass. Endocrinologic studies revealed elevated serum levels of gastrin, vasoactive intestinal polypeptide (VIP), catecholamines, and its metabolites. Surgery was performed successfully without any intraoperative complications, and postoperatively the patient was asymptomatic without further episodes of diarrhea. Histologically the tumor was a pheochromocytoma with neuroendocrine granules of vasoactive intestinal polypeptide and norepinephrine. To our knowledge, there have been six previously reported cases of pheochromocytoma secreting vasoactive intestinal polypeptide. In a patient with secretory diarrhea of unknown etiology, the adrenal glands as well as the pancreas should be examined by ultrasound and/or computerized tomography for the presence of a mass. Should an adrenal mass be discovered, it is necessary to evaluate the tumor for catecholamine production, despite the absence of clinical symptoms of a pheochromocytoma.

No abstract