Primary EGJ outflow obstruction has an unclear clinical significance. A substantial part of patients has unrelated symptoms, spontaneous symptom relief, or no stasis. Treated patients showed a beneficial response to botox injections. A small proportion develops achalasia at follow-up.

With HRM, the presence or absence and size of a hiatal hernia can be assessed with greater sensitivity than with endoscopy or radiography alone.

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In these patients with incidental colonic focal activity undergoing PET/CT (the largest series published to date), malignancies had significantly higher SUVmax values than all other types of lesions. However, SUVmax could not distinguish between benign lesions and adenomas. In conclusion, all incidental findings in the colon should be further evaluated and lesions with SUVmax ≥11.4 should be evaluated without delay.

Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately. (J Neurogastroenterol Motil 2016;22:6-13)

Background and AimsOne of the most used treatments for achalasia is pneumatic dilation of the lower esophageal sphincter to improve esophageal emptying. Multiple treatment protocols have been described with a varying balloon size, number of dilations, inflation pressure, and duration. We aimed to identify the most efficient and safe treatment protocol.MethodsWe performed a systematic review and meta‐analysis of studies on pneumatic dilation in patients with primary achalasia. Clinical remission was defined as an Eckardt score ≤3 or adequate symptom reduction measured with a similar validated questionnaire. We compared the clinical remission rates and occurrence of complications between different treatment protocols.ResultsWe included 10 studies with 643 patients. After 6 months, dilation with a 30‐mm or 35‐mm balloon gave comparable mean success rates (81% and 79%, respectively), whereas a series of dilations up to 40 mm had a higher success rate of 90%. Elective additional dilation in patients with insufficient symptom resolution was somewhat more effective than performing a predefined series of dilations: 86% versus 75% after 12 months. Perforations occurred most often during initial dilations, and significantly more often using a 35‐mm balloon than a 30‐mm balloon (3.2 vs 1.0%); P = 0.027. A subsequent 35‐mm dilation was safer than an initial dilation with 35 mm (0.97% vs 9.3% perforations), P = 0.0017.ConclusionsThe most efficient and safe method of dilating achalasia patients is a graded approach starting with a 30‐mm dilation, followed by an elective 35‐mm dilation and 40 mm when there is insufficient symptom relief.

In this large study that used a database comprising about 25% of all inhabitants of The Netherlands, it is confirmed that achalasia affects individuals of both genders and all ages. The costs associated with diagnosis and treatment of new cases of achalasia increase with increasing age.

In achalasia and spastic esophageal motility disorders, botulinum toxin (botox) injection is considered an effective and low-risk procedure for short-term symptom relief. It is mainly offered to medically high-risk patients. However, no analysis of risks of botox injections has been performed. To determine the incidence and risk factors of procedure-related complications after esophageal botox injections, we analyzed the records of all patients undergoing botox injection therapy for esophageal motility disorders at four university hospitals in Europe and North America between 2008 and 2014. Complications were assigned grades according to the Clavien-Dindo classification. In 386 patients, 661 botox treatments were performed. Main indications were achalasia (51%) and distal esophageal spasm (DES) (30%). In total, 52 (7.9%) mild complications (Clavien-Dindo grade I) were reported by 48 patients, the majority consisting of chest pain or heartburn (29 procedures) or epigastric pain (5 procedures). No ulceration, perforation, pneumothorax, or abscess were reported. One patient died after developing acute mediastinitis (Clavien-Dindo grade V) following injections in the body of the esophagus. In univariate logistic regression, younger age was associated with an increased risk of complications (OR 1.43, 95%CI 1.03-1.96). Treatment for DES, injections into the esophageal body, more injections per procedure, more previous treatments and larger amount of injected botulinum toxin were no risk factors for complications. Esophageal botox injection seems particularly appropriate for high-risk patients due to low complication rate. However, it should not be considered completely safe, as it is associated with rare side effects that cannot be predicted.