| I Clinical Efficacy and Safety of Hot Water Drinking Therapy in Patients with AchalasiaBackgroundThe main therapies of achalasia include medications, botulinum injection, pneumatic dilation and laparoscopic Heller surgery. Those therapies have both advantages and disadvantages. The efficacy of medications lasts shorter and they have got annoying adverse effects such as headaches. Botulinum injection, pneumatic dilation and Heller surgery are all invasive. The relapse rates are highest for botulinum injection and Heller surgery would lead to an impressing incidence of gasrteoesophageal reflux. Although pneumatic dilation has become the first line therapy for achalasia, it has got risks of perforation, relapse and exacerbation of preexisting chest pain. We projected a hot water drinking therapy for achalasia patients based on the fact that most achalasia patients drink water with food to help swallow. The aim of this trial is to test its efficacy and safety.MethodsWe suggested the enrolled patients from the clinics of Peking Union Medical College Hospital, to drink200ml of hot water before and after a meal, to chew carefully and swallow with hot soup, and to drink another200ml of hot water2h before sleep. They were followed on phone call one week later, then had a visit to an expert specialized in achalasia to determine whether to have pneumatic dilation or continue with hot water drinking therapy. For those patients who had pneumatic dilation, they were followed one week and one month later. Then they were asked to stop hot water drinking therapy completely, and had the telephone follow-up one week later. Each follow-up is acompanished with questionnaires, and symptom scores of each item were compared.ResultsThe efficacy of hot water drinking therapy on dysphagia was modest, with a medium rate of50%and had no effect on25%patients. But it is extremely effective on regurgitation with a medium rate of89%, and only3%patients showed no improvement. Hot water drinking could efficiently reduce both the frequency(p=0.002) and the severity (p=0.005) of chest pain attacks. In addition, it is also effective for patients relapsed from pneumatic dilation. The response rates of dilation were higher than hot water drinking alone, but the rates are highest if hot water drinking was added post-dilationally. Hot water drinking had some effect (39%) on the exacerbated chest pain attacks after dilation. Most patients (65%) reported no adverse effect of hot water drinking, but only a few reported mild distention, belching and nausea, which did not interrupt this therapy.ConclusionsHot water drinking therapy showed efficacy for dysphagia, regurgitation and chest pain in achalasia. The response rates of dilation were higher than hot water drinking alone, but rates are highest if hot water drinking therapy was added post-dilationally. Hot water drinking also showed some effect on exacerbated chest pain attacks after dilation. Few patients would have mild effects, which do not interrupt therapy.Ⅱ Effect of Water Drinking on Esophageal Clearance in Patients with AchalasiaBackgroundUpon clinical observation, regurgitation in achalasia was relieved efficiently after hot water drinking therapy and the proposed reason is that water drinking helps to clear the food residue in esophagus. What was more, a few patients were found to have least response when they drank much less water or drank in small sips. This study aimed to testify the above situation and discuss the underlying biophysical mechanism.Methods17patients were from GI clinics in Peking Union Medical College Hospital. They were asked to swallow a gel with barium sulfate and the esophageal transit time was measured by X-ray. Then they were asked to drink40ml of water with meglumine diatrizoate and were categorized into2groups depending on whether the gel could be cleared within2min. Eight patients(not cleared) drank200ml. The transit time and the physical parameters in the X-ray graphs were measured. Nine patients (cleared) drank40ml in4small swallows and the transit time was measured.ResultsThe baseline transit time of gel was>10min for71%of patients. Gel residue was cleared more quickly when the patients drank200ml than40ml (p=0.017), and the fluid level rose more quickly (p=0.036) in that situation. The rise speed of fluid level was found to have a positive relation with the speed of gel clearance (r=0.62, p=0.042). The hydrostatic pressure of fluid column was far lower than LES resting and relaxation pressure. Drink40ml in a continuous way cleared the gel more quickly than drink40ml divided in4cups (p=0.018).ConclusionsHot water drinking therapy can help achalasia patients to clear the food residue in esophagus. And the underlying mechanism lies in the impulse of descending fluid gravity, which might overcome the resistance of LES. Drinking more water (200ml) was found to clear the gel residue more quickly than less water (40ml) and so did continuous drinking than drinking in small sips.Ⅲ Response of Esophagus to High and Low Temperatures in Patients with AchalasiaBackgroundAchalasia patients would sometimes feel exaggerated dysphagia, chest pain and even regurgitation when they drink iced beverages or eat iced food. But the above symptoms would relieve quickly when they drink hot water. Most patients prefer hot food, feeling that "the hot food could open the door between esophagus and stomach". And they avoid iced food as possible as they can. This study aimed to observe how the achalasia esophagus reacts to high and low temperatures.MethodsThirty-six achalasia patients were from GI clinics in Peking Union Medical College Hospital. They were asked to fill in the telephone follow-up questionnaire, including food temperature and associated discomfort. Twelve patients who never had any invasive therapies before were chosen to have high resolution manometry exam. The exam was done in2separated days, with room temperature (25℃)-then hot swallow (50℃) and room temperature (25℃)-then iced swallow respectively. Parameters associated with esophageal motility were analyzed.ResultsThe questionnaires showed56%of patients had exaggerated dysphagia or vomited food they had eaten when they eat iced food.8%had chest pain attacks while only10%had no discomfort. Drinking hot water relieved chest pain, with an efficacy of88%. Iced water increased LES resting pressure (p=0.003), and prolonged the duration of esophageal body contraction (p=0.002). In addition, one patient had pan-esophageal spasm after he swallow iced water. Hot water decreased both LES resting pressure (p=0.008) and residue pressure during swallow (p=0.002), increase LES relaxation rate (p=0.029), shortened the duration of esophageal body contraction (p=0.003).ConclusionsThe iced water could increase LES resting pressure, prolong the contraction duration of esophageal body, and exacerbate dysphagia, regurgitation and chest pain. On the other hand, hot water could reduce LES resting pressure, assist LES relaxation, shorten the contraction duration of esophageal body and relieve symptoms. Hot water drinking therapy is recommended to achalasia patients. Patients are suggested to eat hot and warm food but to avoid iced food.IV Options between Hot Water Drinking Therapy and Pneumatic Dilation in Achalasia PatientsBackgroundAs discussed previously, hot water drinking therapy was found to relieve dysphagia, regurgitation and chest pain in achalasia patients, with fewer efficacies than pneumatic dilation especially on dysphagia. Albeit pneumatic dilation is regarded as the first line therapy, it is confronted with problems such as perforation, the anxiety and fear of patients and also the economic expend. The aim of this research was to find out what kind of paitients are suitable for hot water drinking therapy and on the contrary, suitable for pneumatic dilation.MethodsWe suggested the enrolled patients from the clinics of Peking Union Medical College Hospital, to drink200ml of hot water before and after a meal, to chew carefully and swallow with hot soup, and to drink another200ml of hot water2h before sleep. They were followed on phone call one week later, and then filled the questionnaires. They were finally asked to have a visit to an expert specialized in achalasia to determine whether to have pneumatic dilation or continue with hot water drinking therapy. They were also asked to have the gel clearance exam described in part Ⅱ. Demographic characters, symptom cores, manometry data and gel transit time were compared.ResultsPatients chosen to have dilation were found to have higher LES resting pressure, higher dysphagia score before and after hot water drinking therapy than patients remained to continue with water drinking therapy, with a p-value of0.04,0.008, and 0.001respectively. Calculated by statistical percentiles, we could expect that these patients would have90%of chances to avoid dilation and continue with water drinking therapy, if their LES resting pressure is lower than17mmHg, and they had a dysphagia score of2and1before and after hot water drinking therapy.ConclusionsNot all achalasia patients were candidates for pneumatic dilation as the initial therapy. Hot water drinking remains an alternative for patients with lower LES pressure, lower dysphagia scores before and after drinking therapy. On the other hand, patients who do not meet the previous criteria were candidates for dilation. As for patients who fear about dilation, they could be on hot water drinking therapy on some effect, but need long term clinical follow up. |
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