Volume 81 - 2018 - Fasc.2 - Reviews
Management of esophageal motility disorders in children : a review
Diagnostic criteria for esophageal motor disorders have recently been updated with the advent of high-resolution manometry that gives a precise mapping of peristaltic abnormalities and an indirect view of bolus transit problems. Achalasia, the best-defined motor disorder, is now divided in subsets of manometric phenotypes that predict outcome of treatment and guide our therapeutic approach. Pharmacological therapy using smooth muscle relaxants for spastic esophageal disorders remains poorly effective and used only as a bridge to more effective therapies : endoscopic balloon dilation and surgical myotomy are both effective therapies in achalasia, myotomy being considered as the preferred approach in children because it is aimed to be definitive, while dilations usually have to be repeated. Recently, peroral endoscopic myotomy was introduced as an alternative to surgical myotomy for achalasia, and was rapidly adopted in tertiary referral centers. Showing excellent short-term results, this technique might be also proposed for other esophageal spastic disorders. Gastroesophageal reflux disease and eosinophilic esophagitis, two prevalent diseases in children that may be associated with hypotensive and hypertensive peristaltic abnormalities, have to be searched because specific effective therapies exist for these diseases that may cure the motility disorders. (Acta gastroenterol. belg., 2018, 81, 295-304).
Gastroesophageal variceal bleeding - An overview of current treatment options
Gastroesophageal variceal hemorrhage is the most important clinical event that results from portal hypertension. It is a life- threatening condition that demands rapid and efficient treatment. The first step in bleeding control is hemodynamic stabilization and pharmacological treatment, which includes administration of vasoactive drugs and short-term antibiotic prophylaxis. After initial hemodynamic stabilization, endoscopic therapy should be performed. The first choice of endoscopic treatment for esophageal bleeding is endoscopic variceal ligation (EVL), or endoscopic injection sclerotherapy (EIS) if EVL cannot be performed. Several rescue therapies, such as application of balloon tamponade, a self- expandable metal stent (SEMS), or a transjugular intrahepatic portosystemic shunt (TIPS), are available in cases of resistant variceal bleeding that cannot be controlled with endoscopic therapies.
Gastric varices have a lower incidence than esophageal varices, but bleeding from gastric varices is associated with higher mortality and morbidity rates. The first-line treatment, as with esophageal variceal bleeding, is stabilization of the patient. After that, control of bleeding can be attempted. Optimal management of gastric variceal bleeding is not yet standardized due to diverse underlying pathologies and the lack of large, randomized controlled trials. Among endoscopic techniques, endoscopic variceal obturation (EVO) has been acknowledged as reliable. Among rescue therapies, balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices and TIPS are the most common techniques. (Acta gastroenterol. belg., 2018, 81, 305-316).
Acute non-cirrhotic portal vein thrombosis : review
A 35-year-old men with a medical history of myocardial infarction, presenting with fever, general malaise and vague abdominal discomfort, was diagnosed with a portomesenteric venous thrombosis and acute cytomegalovirus (CMV) infection. Thrombophilia screening resulted in detection of heterozygosity for factor II G20210A gene mutation. Low molecular weight heparin in therapeutic dose was started, followed by disappearance of thrombus on imaging CT two months after diagnosis. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this case and review of the literature. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation.
Acute non-cirrhotic PVT is a rare but probably underestimated condition as symptoms may be discrete or non-specific. The origin of portal thrombosis is frequently multifactorial. Recent literature has emphasized the increasing prevalence of CMV-induced PVT in immunocompetent patients. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this review of the literature and included case. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation. (Acta gastroenterol. belg., 2018, 81, 318- 322).