Re: Taniea possible dilation 3

[Guest guest]

shareedanieal wrote:

> Well I called Dr. Ranne her surgeon to schedule her 3 wk follow up and the

nurse says that she is scheduled for another dilation (number 3) on Monday the

8.

There is dilatation and there is graded dilatation. Some doctors do a

dilatation and that is it, either it works or it does not work. Other

doctors do graded dilatation, starting with a small dilator with a plan

to use bigger dilators until the dilatation takes or they reach a safe

limit.

> Here is my concerns with this he has not seen her in 3 weeks, she has had

so much done already, and while something needs to be done dilating her again in

my lowly opinion not the best answer.

If this is part of his dilatation technique then this may not be as

random as it sounds.

> ... The nurse said if I do not allow him to perform this dilation that he may

not be able to do any more dilations on her which really sent me on a rampage

(sad to say). ...

That kind of statement should be confirmed by the doctor, and I would

ask for the medical reason for it. Is the timing of graded dilatation

that critical? I don't know. Maybe or maybe they are being pushy. My

impression has been that dilatations were as needed until they no longer

have any chance of helping. It would be interesting to know the reason

you were told that.

> I am concerned since this is the only surgeon in our area and he was

recommended from both of her old GI and primary care doctor. But on the other

hand there is something about this doctor that rubs me wrong always has. Am I

being overly cautious?

I don't know that doctor so it is hard to know, but I am glad you are

seeking another opinion.

One thing to consider is that spasms can create difficulty swallowing

that is separate from the problems at the LES which is what myotomy and

dilatation treat. People with DES have bad spasms and can have a very

hard time eating and yet not get any relief from a myotomy or

dilatation. One reason to go to the better medical centers is to be

tested on a high resolution manometry device (not just a standard one)

and be diagnosed by someone with lots of experience with these devices

and these disorders. Sometimes achalasia is just a problem of the LES

but in other cases it can be a bit like DES. If her problems are from

spasms higher up then dilation of the LES may not be helping.

notan

[Guest guest]

Thank you for your help. It was very calming . Dr. Ranne said that he would

do dilations as needed when the subject originally came up but I guess that plan

could have changed. Especially since he has been performing them so regularly.

You make a good point concerning the nurses statement should be questioned

medically. She was diagnosed at the Columbus Childrens Hospital, but I have

thought that maybe she does have DES also I don't know if you can have them

both.

Thank you again

Shamira

________________________________

From: notan ostrich <notan_ostrich@...>

achalasia

Sent: Wed, November 3, 2010 9:19:29 AM

Subject: Re: Taniea possible dilation 3

shareedanieal wrote:

> Well I called Dr. Ranne her surgeon to schedule her 3 wk follow up and the

>nurse says that she is scheduled for another dilation (number 3) on Monday the

>8.

There is dilatation and there is graded dilatation. Some doctors do a

dilatation and that is it, either it works or it does not work. Other

doctors do graded dilatation, starting with a small dilator with a plan

to use bigger dilators until the dilatation takes or they reach a safe

limit.

> Here is my concerns with this he has not seen her in 3 weeks, she has had

so

>much done already, and while something needs to be done dilating her again in

my

>lowly opinion not the best answer.

If this is part of his dilatation technique then this may not be as

random as it sounds.

> ... The nurse said if I do not allow him to perform this dilation that he may

>not be able to do any more dilations on her which really sent me on a rampage

>(sad to say). ...

That kind of statement should be confirmed by the doctor, and I would

ask for the medical reason for it. Is the timing of graded dilatation

that critical? I don't know. Maybe or maybe they are being pushy. My

impression has been that dilatations were as needed until they no longer

have any chance of helping. It would be interesting to know the reason

you were told that.

> I am concerned since this is the only surgeon in our area and he was

>recommended from both of her old GI and primary care doctor. But on the other

>hand there is something about this doctor that rubs me wrong always has. Am I

>being overly cautious?

I don't know that doctor so it is hard to know, but I am glad you are

seeking another opinion.

One thing to consider is that spasms can create difficulty swallowing

that is separate from the problems at the LES which is what myotomy and

dilatation treat. People with DES have bad spasms and can have a very

hard time eating and yet not get any relief from a myotomy or

dilatation. One reason to go to the better medical centers is to be

tested on a high resolution manometry device (not just a standard one)

and be diagnosed by someone with lots of experience with these devices

and these disorders. Sometimes achalasia is just a problem of the LES

but in other cases it can be a bit like DES. If her problems are from

spasms higher up then dilation of the LES may not be helping.

notan

[Guest guest]

Shamira wrote:

> ... She was diagnosed at the Columbus Childrens Hospital, but I have

> thought that maybe she does have DES also I don't know if you can have them

> both.

I don't know what kind of manometry equipment they have at the Columbus

Childrens Hospital or how good they would be at using and interpreting

the results. I think what you want is a medical center that uses High

Resolution Manometry and sees a lot a patients with achalasia. Just

because a place is ranked well in some GI index does not mean they have

that equipment or have many achalasia patients.

I recently posted some links about High Resolution Manometry (HRM). I

will give the links again below. HRM is helping doctors diagnose is a

version of achalasia now called spastic achalasia. Spastic achalasia is

kind of like having both achalasia and DES. In the past with

conventional manometry patients with achalasia like symptoms and

esophageal motility problems tended to be diagnosed as having achalasia,

vigorous achalasia or DES. Now the term vigorous achalasia is gone and

there is now, achalasia, achalasia with pressurization, spastic

achalasia and DES. Some people who in the past would have had a

diagnosis of DES will now have one for spastic achalasia. People who in

the past would have been diagnosed with vigorous achalasia will now

probably be diagnosed with either achalasia with pressurization or

spastic achalasia. The first, with pressurization, tends to have good

results with myotomy but the second, spastic, may not have as much success.

Here is an image of a normal swallow displayed as a 3D

pressure/time/distance map.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F1/

The top of the chart is the UES (top of the esophagus) the bottom is

just after the EsophagoGastric Junction EGJ (where the LES is), which

puts the bottom in the top of the stomach. Time moves from left to

right. Pressure is shown by color, red high, blue low, and the 3D hight

off the page. The red ridge at the top is the UES which has high

pressure almost all the time. The red ridge at the bottom is the from

the LES. It also has high pressure most of the time, but not as high as

the UES. Notice that dip in the UES ridge. That is when the UES relaxed

to let food into the esophagus. That white dashed line marks that moment

in time. That ridge just to the right of that line running diagonally

down and right is the pressure of peristalsis moving the food down as

time moves to the right. That dashed white rectangle marks the length of

the EGJ in hight and the time from the bigging of peristalsis to the end

of peristalsis in width. You can see that the pressure at the EGJ drops

when the peristaltic wave gets close above it because the color goes

from red to yellow. The yellow marks the LES relaxing to let food into

the stomach.

Now look at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F3/

Ignore image A. Images B, C and D are all types of achalasia. Notice

that in all of them that diagonal ridge of peristalsis is missing.

Achalasia lacks esophageal peristalsis. It is hard to see the dip in

pressure at the UES where peristalsis should start but you can see the

peek in UES pressure that follows it. Also notice that in images B and

C the pressure at the EGJ is into the dark red like the UES. In image B

nothing replaces the peristalsis and there is no time the LES relaxes,

so the EGJ just stays red. This is classic achalasia. In image C the

LES does have a time where it relaxes some but there was no peristalsis

to move the food to it and it didn't completely relax. Also in C there

are two moments where the UES and especially the LES increase in

pressure while at the same time the esophagus is shortened. This is like

squeezing a balloon, the pressure goes up in all of the balloon at the

same moment. In this case you see these two increases as two orange

columns. You can tell the esophagus shortened because the red ridge at

the bottom is moved up a little at that time. This is achalasia with

pressurization. In image D peristalsis is replaced by a large spasm of

high pressure. This spasm is going to squeeze so hard that it will block

food. Even if the LES relaxed at that time or had a myotomy the spasm

would block the food. In this image there is a relaxation of the LES

after the spasm but then there is no more pressure above the LES to push

the food through it. This is achalasia with spasm. The spasm in that

image only lasted for about 15 seconds. When people here discuss spasms

that cause pain they may be talking about spasms that last hours.

Now take a look at this conventional manometry image:

http://www.hopkins-gi.org/Upload/200802291326_55692_000.jpg

On the right is a normal chart and the one on the right is achalasia

with something like the achalasia of image C in the other set. You can

see the equipment HRM provides better data.

For someone that has already had a myotomy but is still having problems

this data could be useful in determining if the difficulty is due to

high pressure or some other kind of stricture. If it is because of high

pressure is it because of spasms or because of an incomplete myotomy? If

it is because of spasm is the spasm limited to an area that my benefit

from extending the myotomy? The high resolution can pinpoint the area of

troubling pressure and help determine a treatment.

I can't say that if you go to a center that has this equipment that they

will use it but at least you know that if they decide to do another

manometry that they will get the best data.

Here are those other links.

Has high-resolution manometry changed the approach to esophageal

motility disorders?

http://www.ncbi.nlm.nih.gov/pubmed/20502325

" By reproducibly subtyping achalasia into classic achalasia, achalasia

with pressurization, or spastic achalasia with differential responses to

treatment, HRM has potential to predict clinical outcomes. ... Improved,

accurate and reproducible recognition of manometric diagnoses by HRM

will allow the clinician to confidently diagnose esophageal disorders

such as achalasia, direct therapy and predict outcomes. "

Esophageal motor disorders in terms of high-resolution esophageal

pressure topography: what has changed?

http://www.ncbi.nlm.nih.gov/pubmed/20179690

" Ultimately, clinical experience will be the judge, but it seems likely

that HREPT data, along with its well-defined functional implications,

will improve the clinical management of esophageal motility disorders. "

Achalasia: a new clinically relevant classification by high-resolution

manometry.

http://www.ncbi.nlm.nih.gov/pubmed/18722376

" ... 3 distinct patterns of aperistalsis are discernable with

high-resolution manometry (HRM). ... analysis found type II to be a

predictor of positive treatment response, whereas type III and

pretreatment esophageal dilatation were predictive of negative treatment

response. "

notan

[Guest guest]

Notan,

You rock! My daughter was diagnosed with vigorous A. I have printed you recent

email to take to the dr. with me and a list of my questions. I will be

contacting the hospitals to see which has the hrm. I don't know how to thank

you enough to show how excited I am.

But THANK YOU!!!!!!!

Shamira

________________________________

From: notan ostrich <notan_ostrich@...>

achalasia

Sent: Thu, November 4, 2010 8:15:49 PM

Subject: Re: Taniea possible dilation 3

Shamira wrote:

> ... She was diagnosed at the Columbus Childrens Hospital, but I have

> thought that maybe she does have DES also I don't know if you can have them

> both.

I don't know what kind of manometry equipment they have at the Columbus

Childrens Hospital or how good they would be at using and interpreting

the results. I think what you want is a medical center that uses High

Resolution Manometry and sees a lot a patients with achalasia. Just

because a place is ranked well in some GI index does not mean they have

that equipment or have many achalasia patients.

I recently posted some links about High Resolution Manometry (HRM). I

will give the links again below. HRM is helping doctors diagnose is a

version of achalasia now called spastic achalasia. Spastic achalasia is

kind of like having both achalasia and DES. In the past with

conventional manometry patients with achalasia like symptoms and

esophageal motility problems tended to be diagnosed as having achalasia,

vigorous achalasia or DES. Now the term vigorous achalasia is gone and

there is now, achalasia, achalasia with pressurization, spastic

achalasia and DES. Some people who in the past would have had a

diagnosis of DES will now have one for spastic achalasia. People who in

the past would have been diagnosed with vigorous achalasia will now

probably be diagnosed with either achalasia with pressurization or

spastic achalasia. The first, with pressurization, tends to have good

results with myotomy but the second, spastic, may not have as much success.

Here is an image of a normal swallow displayed as a 3D

pressure/time/distance map.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F1/

The top of the chart is the UES (top of the esophagus) the bottom is

just after the EsophagoGastric Junction EGJ (where the LES is), which

puts the bottom in the top of the stomach. Time moves from left to

right. Pressure is shown by color, red high, blue low, and the 3D hight

off the page. The red ridge at the top is the UES which has high

pressure almost all the time. The red ridge at the bottom is the from

the LES. It also has high pressure most of the time, but not as high as

the UES. Notice that dip in the UES ridge. That is when the UES relaxed

to let food into the esophagus. That white dashed line marks that moment

in time. That ridge just to the right of that line running diagonally

down and right is the pressure of peristalsis moving the food down as

time moves to the right. That dashed white rectangle marks the length of

the EGJ in hight and the time from the bigging of peristalsis to the end

of peristalsis in width. You can see that the pressure at the EGJ drops

when the peristaltic wave gets close above it because the color goes

from red to yellow. The yellow marks the LES relaxing to let food into

the stomach.

Now look at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F3/

Ignore image A. Images B, C and D are all types of achalasia. Notice

that in all of them that diagonal ridge of peristalsis is missing.

Achalasia lacks esophageal peristalsis. It is hard to see the dip in

pressure at the UES where peristalsis should start but you can see the

peek in UES pressure that follows it. Also notice that in images B and

C the pressure at the EGJ is into the dark red like the UES. In image B

nothing replaces the peristalsis and there is no time the LES relaxes,

so the EGJ just stays red. This is classic achalasia. In image C the

LES does have a time where it relaxes some but there was no peristalsis

to move the food to it and it didn't completely relax. Also in C there

are two moments where the UES and especially the LES increase in

pressure while at the same time the esophagus is shortened. This is like

squeezing a balloon, the pressure goes up in all of the balloon at the

same moment. In this case you see these two increases as two orange

columns. You can tell the esophagus shortened because the red ridge at

the bottom is moved up a little at that time. This is achalasia with

pressurization. In image D peristalsis is replaced by a large spasm of

high pressure. This spasm is going to squeeze so hard that it will block

food. Even if the LES relaxed at that time or had a myotomy the spasm

would block the food. In this image there is a relaxation of the LES

after the spasm but then there is no more pressure above the LES to push

the food through it. This is achalasia with spasm. The spasm in that

image only lasted for about 15 seconds. When people here discuss spasms

that cause pain they may be talking about spasms that last hours.

Now take a look at this conventional manometry image:

http://www.hopkins-gi.org/Upload/200802291326_55692_000.jpg

On the right is a normal chart and the one on the right is achalasia

with something like the achalasia of image C in the other set. You can

see the equipment HRM provides better data.

For someone that has already had a myotomy but is still having problems

this data could be useful in determining if the difficulty is due to

high pressure or some other kind of stricture. If it is because of high

pressure is it because of spasms or because of an incomplete myotomy? If

it is because of spasm is the spasm limited to an area that my benefit

from extending the myotomy? The high resolution can pinpoint the area of

troubling pressure and help determine a treatment.

I can't say that if you go to a center that has this equipment that they

will use it but at least you know that if they decide to do another

manometry that they will get the best data.

Here are those other links.

Has high-resolution manometry changed the approach to esophageal

motility disorders?

http://www.ncbi.nlm.nih.gov/pubmed/20502325

" By reproducibly subtyping achalasia into classic achalasia, achalasia

with pressurization, or spastic achalasia with differential responses to

treatment, HRM has potential to predict clinical outcomes. ... Improved,

accurate and reproducible recognition of manometric diagnoses by HRM

will allow the clinician to confidently diagnose esophageal disorders

such as achalasia, direct therapy and predict outcomes. "

Esophageal motor disorders in terms of high-resolution esophageal

pressure topography: what has changed?

http://www.ncbi.nlm.nih.gov/pubmed/20179690

" Ultimately, clinical experience will be the judge, but it seems likely

that HREPT data, along with its well-defined functional implications,

will improve the clinical management of esophageal motility disorders. "

Achalasia: a new clinically relevant classification by high-resolution

manometry.

http://www.ncbi.nlm.nih.gov/pubmed/18722376

" ... 3 distinct patterns of aperistalsis are discernable with

high-resolution manometry (HRM). ... analysis found type II to be a

predictor of positive treatment response, whereas type III and

pretreatment esophageal dilatation were predictive of negative treatment

response. "

notan

[Guest guest]

Notan does rock... we all appreciate and acknowledge that he is the Achalasia

Guru.. I would have to say he knows more about Achalasia than most of the

doctors currently claiming to be " specialists " .

Shamira, where did you decide to go? Did you talk with Dr. Patti?  What

happened with that.. ?

He can also recommend someone closer if there is any one.

Glad you are getting things figured out, albeit slowly..

Carolyn

mom to Cameron

in No. Ca

> ... She was diagnosed at the Columbus Childrens Hospital, but I have

> thought that maybe she does have DES also I don't know if you can have them

> both.

I don't know what kind of manometry equipment they have at the Columbus

Childrens Hospital or how good they would be at using and interpreting

the results. I think what you want is a medical center that uses High

Resolution Manometry and sees a lot a patients with achalasia. Just

because a place is ranked well in some GI index does not mean they have

that equipment or have many achalasia patients.

I recently posted some links about High Resolution Manometry (HRM). I

will give the links again below. HRM is helping doctors diagnose is a

version of achalasia now called spastic achalasia. Spastic achalasia is

kind of like having both achalasia and DES. In the past with

conventional manometry patients with achalasia like symptoms and

esophageal motility problems tended to be diagnosed as having achalasia,

vigorous achalasia or DES. Now the term vigorous achalasia is gone and

there is now, achalasia, achalasia with pressurization, spastic

achalasia and DES. Some people who in the past would have had a

diagnosis of DES will now have one for spastic achalasia. People who in

the past would have been diagnosed with vigorous achalasia will now

probably be diagnosed with either achalasia with pressurization or

spastic achalasia. The first, with pressurization, tends to have good

results with myotomy but the second, spastic, may not have as much success.

Here is an image of a normal swallow displayed as a 3D

pressure/time/distance map.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F1/

The top of the chart is the UES (top of the esophagus) the bottom is

just after the EsophagoGastric Junction EGJ (where the LES is), which

puts the bottom in the top of the stomach. Time moves from left to

right. Pressure is shown by color, red high, blue low, and the 3D hight

off the page. The red ridge at the top is the UES which has high

pressure almost all the time. The red ridge at the bottom is the from

the LES. It also has high pressure most of the time, but not as high as

the UES. Notice that dip in the UES ridge. That is when the UES relaxed

to let food into the esophagus. That white dashed line marks that moment

in time. That ridge just to the right of that line running diagonally

down and right is the pressure of peristalsis moving the food down as

time moves to the right. That dashed white rectangle marks the length of

the EGJ in hight and the time from the bigging of peristalsis to the end

of peristalsis in width. You can see that the pressure at the EGJ drops

when the peristaltic wave gets close above it because the color goes

from red to yellow. The yellow marks the LES relaxing to let food into

the stomach.

Now look at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F3/

Ignore image A. Images B, C and D are all types of achalasia. Notice

that in all of them that diagonal ridge of peristalsis is missing.

Achalasia lacks esophageal peristalsis. It is hard to see the dip in

pressure at the UES where peristalsis should start but you can see the

peek in UES pressure that follows it. Also notice that in images B and

C the pressure at the EGJ is into the dark red like the UES. In image B

nothing replaces the peristalsis and there is no time the LES relaxes,

so the EGJ just stays red. This is classic achalasia. In image C the

LES does have a time where it relaxes some but there was no peristalsis

to move the food to it and it didn't completely relax. Also in C there

are two moments where the UES and especially the LES increase in

pressure while at the same time the esophagus is shortened. This is like

squeezing a balloon, the pressure goes up in all of the balloon at the

same moment. In this case you see these two increases as two orange

columns. You can tell the esophagus shortened because the red ridge at

the bottom is moved up a little at that time. This is achalasia with

pressurization. In image D peristalsis is replaced by a large spasm of

high pressure. This spasm is going to squeeze so hard that it will block

food. Even if the LES relaxed at that time or had a myotomy the spasm

would block the food. In this image there is a relaxation of the LES

after the spasm but then there is no more pressure above the LES to push

the food through it. This is achalasia with spasm. The spasm in that

image only lasted for about 15 seconds. When people here discuss spasms

that cause pain they may be talking about spasms that last hours.

Now take a look at this conventional manometry image:

http://www.hopkins-gi.org/Upload/200802291326_55692_000.jpg

On the right is a normal chart and the one on the right is achalasia

with something like the achalasia of image C in the other set. You can

see the equipment HRM provides better data.

For someone that has already had a myotomy but is still having problems

this data could be useful in determining if the difficulty is due to

high pressure or some other kind of stricture. If it is because of high

pressure is it because of spasms or because of an incomplete myotomy? If

it is because of spasm is the spasm limited to an area that my benefit

from extending the myotomy? The high resolution can pinpoint the area of

troubling pressure and help determine a treatment.

I can't say that if you go to a center that has this equipment that they

will use it but at least you know that if they decide to do another

manometry that they will get the best data.

Here are those other links.

Has high-resolution manometry changed the approach to esophageal

motility disorders?

http://www.ncbi.nlm.nih.gov/pubmed/20502325

" By reproducibly subtyping achalasia into classic achalasia, achalasia

with pressurization, or spastic achalasia with differential responses to

treatment, HRM has potential to predict clinical outcomes. ... Improved,

accurate and reproducible recognition of manometric diagnoses by HRM

will allow the clinician to confidently diagnose esophageal disorders

such as achalasia, direct therapy and predict outcomes. "

Esophageal motor disorders in terms of high-resolution esophageal

pressure topography: what has changed?

http://www.ncbi.nlm.nih.gov/pubmed/20179690

" Ultimately, clinical experience will be the judge, but it seems likely

that HREPT data, along with its well-defined functional implications,

will improve the clinical management of esophageal motility disorders. "

Achalasia: a new clinically relevant classification by high-resolution

manometry.

http://www.ncbi.nlm.nih.gov/pubmed/18722376

" ... 3 distinct patterns of aperistalsis are discernable with

high-resolution manometry (HRM). ... analysis found type II to be a

predictor of positive treatment response, whereas type III and

pretreatment esophageal dilatation were predictive of negative treatment

response. "

notan

[Guest guest]

Notan,

I took the information you have given me to Taniea's pediatrician and she was

also impressed with you knowledge. But I was wondering if you could tell me

based on the outdated information what is the difference between Vigorous A and

the other subtypes? When I asked her former GI and the surgeon they really just

stumbled around the question and the surgeon said as he laughed (I am sure out

of embarrassment) she has classic A.

Thank you

Shamira

________________________________

From: notan ostrich <notan_ostrich@...>

achalasia

Sent: Thu, November 4, 2010 8:15:49 PM

Subject: Re: Taniea possible dilation 3

Shamira wrote:

> ... She was diagnosed at the Columbus Childrens Hospital, but I have

> thought that maybe she does have DES also I don't know if you can have them

> both.

I don't know what kind of manometry equipment they have at the Columbus

Childrens Hospital or how good they would be at using and interpreting

the results. I think what you want is a medical center that uses High

Resolution Manometry and sees a lot a patients with achalasia. Just

because a place is ranked well in some GI index does not mean they have

that equipment or have many achalasia patients.

I recently posted some links about High Resolution Manometry (HRM). I

will give the links again below. HRM is helping doctors diagnose is a

version of achalasia now called spastic achalasia. Spastic achalasia is

kind of like having both achalasia and DES. In the past with

conventional manometry patients with achalasia like symptoms and

esophageal motility problems tended to be diagnosed as having achalasia,

vigorous achalasia or DES. Now the term vigorous achalasia is gone and

there is now, achalasia, achalasia with pressurization, spastic

achalasia and DES. Some people who in the past would have had a

diagnosis of DES will now have one for spastic achalasia. People who in

the past would have been diagnosed with vigorous achalasia will now

probably be diagnosed with either achalasia with pressurization or

spastic achalasia. The first, with pressurization, tends to have good

results with myotomy but the second, spastic, may not have as much success.

Here is an image of a normal swallow displayed as a 3D

pressure/time/distance map.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F1/

The top of the chart is the UES (top of the esophagus) the bottom is

just after the EsophagoGastric Junction EGJ (where the LES is), which

puts the bottom in the top of the stomach. Time moves from left to

right. Pressure is shown by color, red high, blue low, and the 3D hight

off the page. The red ridge at the top is the UES which has high

pressure almost all the time. The red ridge at the bottom is the from

the LES. It also has high pressure most of the time, but not as high as

the UES. Notice that dip in the UES ridge. That is when the UES relaxed

to let food into the esophagus. That white dashed line marks that moment

in time. That ridge just to the right of that line running diagonally

down and right is the pressure of peristalsis moving the food down as

time moves to the right. That dashed white rectangle marks the length of

the EGJ in hight and the time from the bigging of peristalsis to the end

of peristalsis in width. You can see that the pressure at the EGJ drops

when the peristaltic wave gets close above it because the color goes

from red to yellow. The yellow marks the LES relaxing to let food into

the stomach.

Now look at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888528/figure/F3/

Ignore image A. Images B, C and D are all types of achalasia. Notice

that in all of them that diagonal ridge of peristalsis is missing.

Achalasia lacks esophageal peristalsis. It is hard to see the dip in

pressure at the UES where peristalsis should start but you can see the

peek in UES pressure that follows it. Also notice that in images B and

C the pressure at the EGJ is into the dark red like the UES. In image B

nothing replaces the peristalsis and there is no time the LES relaxes,

so the EGJ just stays red. This is classic achalasia. In image C the

LES does have a time where it relaxes some but there was no peristalsis

to move the food to it and it didn't completely relax. Also in C there

are two moments where the UES and especially the LES increase in

pressure while at the same time the esophagus is shortened. This is like

squeezing a balloon, the pressure goes up in all of the balloon at the

same moment. In this case you see these two increases as two orange

columns. You can tell the esophagus shortened because the red ridge at

the bottom is moved up a little at that time. This is achalasia with

pressurization. In image D peristalsis is replaced by a large spasm of

high pressure. This spasm is going to squeeze so hard that it will block

food. Even if the LES relaxed at that time or had a myotomy the spasm

would block the food. In this image there is a relaxation of the LES

after the spasm but then there is no more pressure above the LES to push

the food through it. This is achalasia with spasm. The spasm in that

image only lasted for about 15 seconds. When people here discuss spasms

that cause pain they may be talking about spasms that last hours.

Now take a look at this conventional manometry image:

http://www.hopkins-gi.org/Upload/200802291326_55692_000.jpg

On the right is a normal chart and the one on the right is achalasia

with something like the achalasia of image C in the other set. You can

see the equipment HRM provides better data.

For someone that has already had a myotomy but is still having problems

this data could be useful in determining if the difficulty is due to

high pressure or some other kind of stricture. If it is because of high

pressure is it because of spasms or because of an incomplete myotomy? If

it is because of spasm is the spasm limited to an area that my benefit

from extending the myotomy? The high resolution can pinpoint the area of

troubling pressure and help determine a treatment.

I can't say that if you go to a center that has this equipment that they

will use it but at least you know that if they decide to do another

manometry that they will get the best data.

Here are those other links.

Has high-resolution manometry changed the approach to esophageal

motility disorders?

http://www.ncbi.nlm.nih.gov/pubmed/20502325

" By reproducibly subtyping achalasia into classic achalasia, achalasia

with pressurization, or spastic achalasia with differential responses to

treatment, HRM has potential to predict clinical outcomes. ... Improved,

accurate and reproducible recognition of manometric diagnoses by HRM

will allow the clinician to confidently diagnose esophageal disorders

such as achalasia, direct therapy and predict outcomes. "

Esophageal motor disorders in terms of high-resolution esophageal

pressure topography: what has changed?

http://www.ncbi.nlm.nih.gov/pubmed/20179690

" Ultimately, clinical experience will be the judge, but it seems likely

that HREPT data, along with its well-defined functional implications,

will improve the clinical management of esophageal motility disorders. "

Achalasia: a new clinically relevant classification by high-resolution

manometry.

http://www.ncbi.nlm.nih.gov/pubmed/18722376

" ... 3 distinct patterns of aperistalsis are discernable with

high-resolution manometry (HRM). ... analysis found type II to be a

predictor of positive treatment response, whereas type III and

pretreatment esophageal dilatation were predictive of negative treatment

response. "

notan

[Guest guest]

Shamira wrote:

> ... I was wondering if you could tell me

> based on the outdated information what is the difference between Vigorous A

and

> the other subtypes?

It depends on which authors you read. In the least restrictive view it

is simply achalasia with pain. The pain is believed to be from more

forceful (vigorous) spasms than are found in non vigorous achalasia.

Seems clear up to this point. Then some researchers tried to define it

in terms of conventional manometry and radiology findings. In manometry

vigorous achalasia could be defined by spasms that were above a certain

pressure in the context of achalasia. In radiology it may look like

achalasia with the spasms of DES. This seems logical. Then studies are

done using these criteria and find that non vigorous achalasia patients

have as much pain as vigorous achalasia patients. Other studies are done

and some report that vigorous achalasia is a predictor of bad treatment

outcome while others report there is no difference in outcomes. What

gives? Time for more background.

Achalasia presents in different ways. There may or may not be a birds

beak image with barium. There may or may not be dilation of the

esophagus. There may or may not be high pressure at the LES. There may

or may not be some complete relaxations of the LES. There may or may

not be simultaneous contractions of the esophageal body (common

cavity/pressurization). There may or may not be spasms in the esophageal

body other than the LES. There may or may not be pain. There is always a

dysfunction of peristalsis.

Authors may differ but classic achalasia has a birds beak, some

dilation, aperistalsis, and a failure of the LES to completely relax.

Whatever else is going on, or not going on, these symptoms are classic

for achalasia. In DES most swallows may be completely normal, but if

enough of them result in spasms then DES is considered. Typically in DES

the spasms are in the lower esophagus, are simultaneous and may have

high pressure. If most swallows are normal but there are those spasm you

probably have DES but if you are classic for achalasia and have those

spasms you probably have vigorous achalasia. If you are not classic but

have the spasms then things are not so clear. Also, what may seem like

that simultaneous contractions of esophagus may just be common cavity

pressurization.

The short answer is that whether a patient had vigorous achalasia or not

depended on where he was diagnosed and what tests were done, and the

results of studies may have depended on where those studies were done.

Now the doctors with high resolution manometry think they can better

define and diagnose the different forms of achalasia.

> When I asked her former GI and the surgeon they really just

> stumbled around the question and the surgeon said as he laughed (I am sure out

> of embarrassment) she has classic A.

OK, not DES, but if vigorous, is it more like pressurization or like the

DES spasms?

notan

[Guest guest]

We went to the surgeons office today and he said that he is moving to Texas

which is why he will not be able to do any more dilations. He also said that he

didn't intend on doing the one on Monday and that it was a miss communication in

the office. He said that he would refer her back to Dr. Donovan her previous GI

for further treatment. Also, he said that since she is young that there will be

quite a bit of scarring but that she needs to drink a lot of water while eating.

but she drinks at home and still spits up so we will see I guess. The good news

is she says she has no more pain or at least that is what she at the surgeons

and the semi bad news we have no surgeon or GI and that the moment.

> > ... I was wondering if you could tell me

> > based on the outdated information what is the difference between Vigorous A

and

> > the other subtypes?

>

> It depends on which authors you read. In the least restrictive view it

> is simply achalasia with pain. The pain is believed to be from more

> forceful (vigorous) spasms than are found in non vigorous achalasia.

> Seems clear up to this point. Then some researchers tried to define it

> in terms of conventional manometry and radiology findings. In manometry

> vigorous achalasia could be defined by spasms that were above a certain

> pressure in the context of achalasia. In radiology it may look like

> achalasia with the spasms of DES. This seems logical. Then studies are

> done using these criteria and find that non vigorous achalasia patients

> have as much pain as vigorous achalasia patients. Other studies are done

> and some report that vigorous achalasia is a predictor of bad treatment

> outcome while others report there is no difference in outcomes. What

> gives? Time for more background.

>

> Achalasia presents in different ways. There may or may not be a birds

> beak image with barium. There may or may not be dilation of the

> esophagus. There may or may not be high pressure at the LES. There may

> or may not be some complete relaxations of the LES. There may or may

> not be simultaneous contractions of the esophageal body (common

> cavity/pressurization). There may or may not be spasms in the esophageal

> body other than the LES. There may or may not be pain. There is always a

> dysfunction of peristalsis.

>

> Authors may differ but classic achalasia has a birds beak, some

> dilation, aperistalsis, and a failure of the LES to completely relax.

> Whatever else is going on, or not going on, these symptoms are classic

> for achalasia. In DES most swallows may be completely normal, but if

> enough of them result in spasms then DES is considered. Typically in DES

> the spasms are in the lower esophagus, are simultaneous and may have

> high pressure. If most swallows are normal but there are those spasm you

> probably have DES but if you are classic for achalasia and have those

> spasms you probably have vigorous achalasia. If you are not classic but

> have the spasms then things are not so clear. Also, what may seem like

> that simultaneous contractions of esophagus may just be common cavity

> pressurization.

>

> The short answer is that whether a patient had vigorous achalasia or not

> depended on where he was diagnosed and what tests were done, and the

> results of studies may have depended on where those studies were done.

>

> Now the doctors with high resolution manometry think they can better

> define and diagnose the different forms of achalasia.

>

>

> > When I asked her former GI and the surgeon they really just

> > stumbled around the question and the surgeon said as he laughed (I am sure

out

> > of embarrassment) she has classic A.

>

> OK, not DES, but if vigorous, is it more like pressurization or like the

> DES spasms?

>

> notan

>

[Guest guest]

Again, I cannot stress enough how worth every cent, every moment, every minute

traveling, every phone call to get to the best surgeon you can.. Scar tissue is

a huge issue in a child.

Never heard if you contacted Dr. Patti back..

CArolyn

mom of Cameron

in CA

> > > ... I was wondering if you could tell me

> > > based on the outdated information what is the difference between Vigorous

A and

> > > the other subtypes?

> >

> > It depends on which authors you read. In the least restrictive view it

> > is simply achalasia with pain. The pain is believed to be from more

> > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > Seems clear up to this point. Then some researchers tried to define it

> > in terms of conventional manometry and radiology findings. In manometry

> > vigorous achalasia could be defined by spasms that were above a certain

> > pressure in the context of achalasia. In radiology it may look like

> > achalasia with the spasms of DES. This seems logical. Then studies are

> > done using these criteria and find that non vigorous achalasia patients

> > have as much pain as vigorous achalasia patients. Other studies are done

> > and some report that vigorous achalasia is a predictor of bad treatment

> > outcome while others report there is no difference in outcomes. What

> > gives? Time for more background.

> >

> > Achalasia presents in different ways. There may or may not be a birds

> > beak image with barium. There may or may not be dilation of the

> > esophagus. There may or may not be high pressure at the LES. There may

> > or may not be some complete relaxations of the LES. There may or may

> > not be simultaneous contractions of the esophageal body (common

> > cavity/pressurization). There may or may not be spasms in the esophageal

> > body other than the LES. There may or may not be pain. There is always a

> > dysfunction of peristalsis.

> >

> > Authors may differ but classic achalasia has a birds beak, some

> > dilation, aperistalsis, and a failure of the LES to completely relax.

> > Whatever else is going on, or not going on, these symptoms are classic

> > for achalasia. In DES most swallows may be completely normal, but if

> > enough of them result in spasms then DES is considered. Typically in DES

> > the spasms are in the lower esophagus, are simultaneous and may have

> > high pressure. If most swallows are normal but there are those spasm you

> > probably have DES but if you are classic for achalasia and have those

> > spasms you probably have vigorous achalasia. If you are not classic but

> > have the spasms then things are not so clear. Also, what may seem like

> > that simultaneous contractions of esophagus may just be common cavity

> > pressurization.

> >

> > The short answer is that whether a patient had vigorous achalasia or not

> > depended on where he was diagnosed and what tests were done, and the

> > results of studies may have depended on where those studies were done.

> >

> > Now the doctors with high resolution manometry think they can better

> > define and diagnose the different forms of achalasia.

> >

> >

> > > When I asked her former GI and the surgeon they really just

> > > stumbled around the question and the surgeon said as he laughed (I am sure

out

> > > of embarrassment) she has classic A.

> >

> > OK, not DES, but if vigorous, is it more like pressurization or like the

> > DES spasms?

> >

> > notan

> >

>

[Guest guest]

I a gee with Carolyn. I thought you had contacted the three sugeons that we

mentioned? What is the status on that? She needs expert care and waiting isn't

helping. Your local guys don't have the knowledge to see her through to the next

level. You really should plan on seeing a top surgeon.

> > > > ... I was wondering if you could tell me

> > > > based on the outdated information what is the difference between

Vigorous A and

> > > > the other subtypes?

> > >

> > > It depends on which authors you read. In the least restrictive view it

> > > is simply achalasia with pain. The pain is believed to be from more

> > > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > > Seems clear up to this point. Then some researchers tried to define it

> > > in terms of conventional manometry and radiology findings. In manometry

> > > vigorous achalasia could be defined by spasms that were above a certain

> > > pressure in the context of achalasia. In radiology it may look like

> > > achalasia with the spasms of DES. This seems logical. Then studies are

> > > done using these criteria and find that non vigorous achalasia patients

> > > have as much pain as vigorous achalasia patients. Other studies are done

> > > and some report that vigorous achalasia is a predictor of bad treatment

> > > outcome while others report there is no difference in outcomes. What

> > > gives? Time for more background.

> > >

> > > Achalasia presents in different ways. There may or may not be a birds

> > > beak image with barium. There may or may not be dilation of the

> > > esophagus. There may or may not be high pressure at the LES. There may

> > > or may not be some complete relaxations of the LES. There may or may

> > > not be simultaneous contractions of the esophageal body (common

> > > cavity/pressurization). There may or may not be spasms in the esophageal

> > > body other than the LES. There may or may not be pain. There is always a

> > > dysfunction of peristalsis.

> > >

> > > Authors may differ but classic achalasia has a birds beak, some

> > > dilation, aperistalsis, and a failure of the LES to completely relax.

> > > Whatever else is going on, or not going on, these symptoms are classic

> > > for achalasia. In DES most swallows may be completely normal, but if

> > > enough of them result in spasms then DES is considered. Typically in DES

> > > the spasms are in the lower esophagus, are simultaneous and may have

> > > high pressure. If most swallows are normal but there are those spasm you

> > > probably have DES but if you are classic for achalasia and have those

> > > spasms you probably have vigorous achalasia. If you are not classic but

> > > have the spasms then things are not so clear. Also, what may seem like

> > > that simultaneous contractions of esophagus may just be common cavity

> > > pressurization.

> > >

> > > The short answer is that whether a patient had vigorous achalasia or not

> > > depended on where he was diagnosed and what tests were done, and the

> > > results of studies may have depended on where those studies were done.

> > >

> > > Now the doctors with high resolution manometry think they can better

> > > define and diagnose the different forms of achalasia.

> > >

> > >

> > > > When I asked her former GI and the surgeon they really just

> > > > stumbled around the question and the surgeon said as he laughed (I am

sure out

> > > > of embarrassment) she has classic A.

> > >

> > > OK, not DES, but if vigorous, is it more like pressurization or like the

> > > DES spasms?

> > >

> > > notan

> > >

> >

>

[Guest guest]

Oh sorry I have contacted him. I sent all the information he asked for and more

and he said if have any questions to call his nurse. Oh I have not yet given

up.

Shamira

________________________________

From: Carolyn H <wooleeacre@...>

achalasia

Sent: Fri, November 12, 2010 12:41:09 AM

Subject: Re: Taniea possible dilation 3

Again, I cannot stress enough how worth every cent, every moment, every minute

traveling, every phone call to get to the best surgeon you can.. Scar tissue is

a huge issue in a child.

Never heard if you contacted Dr. Patti back..

CArolyn

mom of Cameron

in CA

> > > ... I was wondering if you could tell me

> > > based on the outdated information what is the difference between Vigorous

A

>and

> > > the other subtypes?

> >

> > It depends on which authors you read. In the least restrictive view it

> > is simply achalasia with pain. The pain is believed to be from more

> > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > Seems clear up to this point. Then some researchers tried to define it

> > in terms of conventional manometry and radiology findings. In manometry

> > vigorous achalasia could be defined by spasms that were above a certain

> > pressure in the context of achalasia. In radiology it may look like

> > achalasia with the spasms of DES. This seems logical. Then studies are

> > done using these criteria and find that non vigorous achalasia patients

> > have as much pain as vigorous achalasia patients. Other studies are done

> > and some report that vigorous achalasia is a predictor of bad treatment

> > outcome while others report there is no difference in outcomes. What

> > gives? Time for more background.

> >

> > Achalasia presents in different ways. There may or may not be a birds

> > beak image with barium. There may or may not be dilation of the

> > esophagus. There may or may not be high pressure at the LES. There may

> > or may not be some complete relaxations of the LES. There may or may

> > not be simultaneous contractions of the esophageal body (common

> > cavity/pressurization). There may or may not be spasms in the esophageal

> > body other than the LES. There may or may not be pain. There is always a

> > dysfunction of peristalsis.

> >

> > Authors may differ but classic achalasia has a birds beak, some

> > dilation, aperistalsis, and a failure of the LES to completely relax.

> > Whatever else is going on, or not going on, these symptoms are classic

> > for achalasia. In DES most swallows may be completely normal, but if

> > enough of them result in spasms then DES is considered. Typically in DES

> > the spasms are in the lower esophagus, are simultaneous and may have

> > high pressure. If most swallows are normal but there are those spasm you

> > probably have DES but if you are classic for achalasia and have those

> > spasms you probably have vigorous achalasia. If you are not classic but

> > have the spasms then things are not so clear. Also, what may seem like

> > that simultaneous contractions of esophagus may just be common cavity

> > pressurization.

> >

> > The short answer is that whether a patient had vigorous achalasia or not

> > depended on where he was diagnosed and what tests were done, and the

> > results of studies may have depended on where those studies were done.

> >

> > Now the doctors with high resolution manometry think they can better

> > define and diagnose the different forms of achalasia.

> >

> >

> > > When I asked her former GI and the surgeon they really just

> > > stumbled around the question and the surgeon said as he laughed (I am sure

>out

> > > of embarrassment) she has classic A.

> >

> > OK, not DES, but if vigorous, is it more like pressurization or like the

> > DES spasms?

> >

> > notan

> >

>

[Guest guest]

Where r u

Sent from my iPhone

On Nov 12, 2010, at 6:44 AM, Shamira <shareedanieal@...> wrote:

> Oh sorry I have contacted him. I sent all the information he asked for and

more

> and he said if have any questions to call his nurse. Oh I have not yet given

> up.

>

> Shamira

>

> ________________________________

> From: Carolyn H <wooleeacre@...>

> achalasia

> Sent: Fri, November 12, 2010 12:41:09 AM

> Subject: Re: Taniea possible dilation 3

>

> Again, I cannot stress enough how worth every cent, every moment, every minute

> traveling, every phone call to get to the best surgeon you can.. Scar tissue

is

> a huge issue in a child.

>

> Never heard if you contacted Dr. Patti back..

> CArolyn

> mom of Cameron

> in CA

>

>

> > > > ... I was wondering if you could tell me

> > > > based on the outdated information what is the difference between

Vigorous A

> >and

> > > > the other subtypes?

> > >

> > > It depends on which authors you read. In the least restrictive view it

> > > is simply achalasia with pain. The pain is believed to be from more

> > > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > > Seems clear up to this point. Then some researchers tried to define it

> > > in terms of conventional manometry and radiology findings. In manometry

> > > vigorous achalasia could be defined by spasms that were above a certain

> > > pressure in the context of achalasia. In radiology it may look like

> > > achalasia with the spasms of DES. This seems logical. Then studies are

> > > done using these criteria and find that non vigorous achalasia patients

> > > have as much pain as vigorous achalasia patients. Other studies are done

> > > and some report that vigorous achalasia is a predictor of bad treatment

> > > outcome while others report there is no difference in outcomes. What

> > > gives? Time for more background.

> > >

> > > Achalasia presents in different ways. There may or may not be a birds

> > > beak image with barium. There may or may not be dilation of the

> > > esophagus. There may or may not be high pressure at the LES. There may

> > > or may not be some complete relaxations of the LES. There may or may

> > > not be simultaneous contractions of the esophageal body (common

> > > cavity/pressurization). There may or may not be spasms in the esophageal

> > > body other than the LES. There may or may not be pain. There is always a

> > > dysfunction of peristalsis.

> > >

> > > Authors may differ but classic achalasia has a birds beak, some

> > > dilation, aperistalsis, and a failure of the LES to completely relax.

> > > Whatever else is going on, or not going on, these symptoms are classic

> > > for achalasia. In DES most swallows may be completely normal, but if

> > > enough of them result in spasms then DES is considered. Typically in DES

> > > the spasms are in the lower esophagus, are simultaneous and may have

> > > high pressure. If most swallows are normal but there are those spasm you

> > > probably have DES but if you are classic for achalasia and have those

> > > spasms you probably have vigorous achalasia. If you are not classic but

> > > have the spasms then things are not so clear. Also, what may seem like

> > > that simultaneous contractions of esophagus may just be common cavity

> > > pressurization.

> > >

> > > The short answer is that whether a patient had vigorous achalasia or not

> > > depended on where he was diagnosed and what tests were done, and the

> > > results of studies may have depended on where those studies were done.

> > >

> > > Now the doctors with high resolution manometry think they can better

> > > define and diagnose the different forms of achalasia.

> > >

> > >

> > > > When I asked her former GI and the surgeon they really just

> > > > stumbled around the question and the surgeon said as he laughed (I am

sure

> >out

> > > > of embarrassment) she has classic A.

> > >

> > > OK, not DES, but if vigorous, is it more like pressurization or like the

> > > DES spasms?

> > >

> > > notan

> > >

> >

>

>

[Guest guest]

Oklahoma

________________________________

From: <shark13sr@...>

" achalasia " <achalasia >

Sent: Fri, November 12, 2010 2:22:41 PM

Subject: Re: Re: Taniea possible dilation 3

Where r u

Sent from my iPhone

On Nov 12, 2010, at 6:44 AM, Shamira <shareedanieal@...> wrote:

> Oh sorry I have contacted him. I sent all the information he asked for and

more

>

> and he said if have any questions to call his nurse. Oh I have not yet given

> up.

>

> Shamira

>

> ________________________________

> From: Carolyn H <wooleeacre@...>

> achalasia

> Sent: Fri, November 12, 2010 12:41:09 AM

> Subject: Re: Taniea possible dilation 3

>

> Again, I cannot stress enough how worth every cent, every moment, every minute

> traveling, every phone call to get to the best surgeon you can.. Scar tissue

is

>

> a huge issue in a child.

>

> Never heard if you contacted Dr. Patti back..

> CArolyn

> mom of Cameron

> in CA

>

>

> > > > ... I was wondering if you could tell me

> > > > based on the outdated information what is the difference between

Vigorous

>A

>

> >and

> > > > the other subtypes?

> > >

> > > It depends on which authors you read. In the least restrictive view it

> > > is simply achalasia with pain. The pain is believed to be from more

> > > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > > Seems clear up to this point. Then some researchers tried to define it

> > > in terms of conventional manometry and radiology findings. In manometry

> > > vigorous achalasia could be defined by spasms that were above a certain

> > > pressure in the context of achalasia. In radiology it may look like

> > > achalasia with the spasms of DES. This seems logical. Then studies are

> > > done using these criteria and find that non vigorous achalasia patients

> > > have as much pain as vigorous achalasia patients. Other studies are done

> > > and some report that vigorous achalasia is a predictor of bad treatment

> > > outcome while others report there is no difference in outcomes. What

> > > gives? Time for more background.

> > >

> > > Achalasia presents in different ways. There may or may not be a birds

> > > beak image with barium. There may or may not be dilation of the

> > > esophagus. There may or may not be high pressure at the LES. There may

> > > or may not be some complete relaxations of the LES. There may or may

> > > not be simultaneous contractions of the esophageal body (common

> > > cavity/pressurization). There may or may not be spasms in the esophageal

> > > body other than the LES. There may or may not be pain. There is always a

> > > dysfunction of peristalsis.

> > >

> > > Authors may differ but classic achalasia has a birds beak, some

> > > dilation, aperistalsis, and a failure of the LES to completely relax.

> > > Whatever else is going on, or not going on, these symptoms are classic

> > > for achalasia. In DES most swallows may be completely normal, but if

> > > enough of them result in spasms then DES is considered. Typically in DES

> > > the spasms are in the lower esophagus, are simultaneous and may have

> > > high pressure. If most swallows are normal but there are those spasm you

> > > probably have DES but if you are classic for achalasia and have those

> > > spasms you probably have vigorous achalasia. If you are not classic but

> > > have the spasms then things are not so clear. Also, what may seem like

> > > that simultaneous contractions of esophagus may just be common cavity

> > > pressurization.

> > >

> > > The short answer is that whether a patient had vigorous achalasia or not

> > > depended on where he was diagnosed and what tests were done, and the

> > > results of studies may have depended on where those studies were done.

> > >

> > > Now the doctors with high resolution manometry think they can better

> > > define and diagnose the different forms of achalasia.

> > >

> > >

> > > > When I asked her former GI and the surgeon they really just

> > > > stumbled around the question and the surgeon said as he laughed (I am

>sure

>

> >out

> > > > of embarrassment) she has classic A.

> > >

> > > OK, not DES, but if vigorous, is it more like pressurization or like the

> > > DES spasms?

> > >

> > > notan

> > >

> >

>

>

[Guest guest]

Hello every one I wanted to update you all on Taniea's progress. She is doing

well has finally learned to chew a bit and she drinks more fluids with meals. I

also heard from dr. Patti and he referred to dr. Pelligrini out of Washington.

He also sent me a copy of her records she was wrapped 270 degrees he called it a

THAL wrap and she was dilated to a 52 french so my question is is that big or

small?

> > > > > ... I was wondering if you could tell me

> > > > > based on the outdated information what is the difference between

Vigorous

> >A

> >

> > >and

> > > > > the other subtypes?

> > > >

> > > > It depends on which authors you read. In the least restrictive view it

> > > > is simply achalasia with pain. The pain is believed to be from more

> > > > forceful (vigorous) spasms than are found in non vigorous achalasia.

> > > > Seems clear up to this point. Then some researchers tried to define it

> > > > in terms of conventional manometry and radiology findings. In manometry

> > > > vigorous achalasia could be defined by spasms that were above a certain

> > > > pressure in the context of achalasia. In radiology it may look like

> > > > achalasia with the spasms of DES. This seems logical. Then studies are

> > > > done using these criteria and find that non vigorous achalasia patients

> > > > have as much pain as vigorous achalasia patients. Other studies are done

> > > > and some report that vigorous achalasia is a predictor of bad treatment

> > > > outcome while others report there is no difference in outcomes. What

> > > > gives? Time for more background.

> > > >

> > > > Achalasia presents in different ways. There may or may not be a birds

> > > > beak image with barium. There may or may not be dilation of the

> > > > esophagus. There may or may not be high pressure at the LES. There may

> > > > or may not be some complete relaxations of the LES. There may or may

> > > > not be simultaneous contractions of the esophageal body (common

> > > > cavity/pressurization). There may or may not be spasms in the esophageal

> > > > body other than the LES. There may or may not be pain. There is always a

> > > > dysfunction of peristalsis.

> > > >

> > > > Authors may differ but classic achalasia has a birds beak, some

> > > > dilation, aperistalsis, and a failure of the LES to completely relax.

> > > > Whatever else is going on, or not going on, these symptoms are classic

> > > > for achalasia. In DES most swallows may be completely normal, but if

> > > > enough of them result in spasms then DES is considered. Typically in DES

> > > > the spasms are in the lower esophagus, are simultaneous and may have

> > > > high pressure. If most swallows are normal but there are those spasm you

> > > > probably have DES but if you are classic for achalasia and have those

> > > > spasms you probably have vigorous achalasia. If you are not classic but

> > > > have the spasms then things are not so clear. Also, what may seem like

> > > > that simultaneous contractions of esophagus may just be common cavity

> > > > pressurization.

> > > >

> > > > The short answer is that whether a patient had vigorous achalasia or not

> > > > depended on where he was diagnosed and what tests were done, and the

> > > > results of studies may have depended on where those studies were done.

> > > >

> > > > Now the doctors with high resolution manometry think they can better

> > > > define and diagnose the different forms of achalasia.

> > > >

> > > >

> > > > > When I asked her former GI and the surgeon they really just

> > > > > stumbled around the question and the surgeon said as he laughed (I am

> >sure

> >

> > >out

> > > > > of embarrassment) she has classic A.

> > > >

> > > > OK, not DES, but if vigorous, is it more like pressurization or like the

> > > > DES spasms?

> > > >

> > > > notan

> > > >

> > >

> >

> >

[Guest guest]

Shamira wrote:

> ... she was wrapped 270 degrees he called it a THAL wrap and she was dilated

to a 52 french so my question is is that big or small?

A French, is a unit of the French scale or French gauge system not to be

confused with the Mille (French). Just divide the french (Fr) by 3 to

get mm. 52 Fr = about 17 mm. That is not an " achalasia " dilator. It is

about half the size of an adult achalasia dilator 30mm - 45mm, which

could be too big for a child.

The THAL wrap, like the dor is done in front of the esophagus covering

the myotomy unlike the Toupee which goes behind. Like the Toupee it is

270 degrees unlike the dor which is 180. It is used in children without

achalasia that have reflux problems, and in that context there has been

a lot of experience in children with it. I don't remember anyone else

saying they had that one in this support group though.

notan

[Guest guest]

Hmmn... thank you Notan for your response. I wonder though it says on October

15th she was dilated from a 38 to 52 is this more then 2 sizes? I read

somewhere that it's suggested not to dilate more then 2 sizes... aww questions

questions.

Thank you

Shamira

________________________________

From: notan ostrich <notan_ostrich@...>

achalasia

Sent: Sun, January 2, 2011 6:08:49 PM

Subject: Re: Re: Taniea possible dilation 3

Shamira wrote:

> ... she was wrapped 270 degrees he called it a THAL wrap and she was dilated

to

>a 52 french so my question is is that big or small?

A French, is a unit of the French scale or French gauge system not to be

confused with the Mille (French). Just divide the french (Fr) by 3 to

get mm. 52 Fr = about 17 mm. That is not an " achalasia " dilator. It is

about half the size of an adult achalasia dilator 30mm - 45mm, which

could be too big for a child.

The THAL wrap, like the dor is done in front of the esophagus covering

the myotomy unlike the Toupee which goes behind. Like the Toupee it is

270 degrees unlike the dor which is 180. It is used in children without

achalasia that have reflux problems, and in that context there has been

a lot of experience in children with it. I don't remember anyone else

saying they had that one in this support group though.

notan