Reviewer's report 
 Anorectal motility in patients with achalasia of the esophegus: recognition of an Title: 
esophago-rectal syndrom 
Authors: 
Prof Ahmed A Shafik ( ashafik@ahmedshafik.org )
 1  22 Apr 2003 Version: Date: 
 Philip Donahue Reviewer: 
 A paper of considerable general medical or scientific interest Level of interest: 
 Other (see below) Advice on publication: 
Anorectal and colonic motility in patients with achalasia can be affected 
by anganglionosis, and this study provides some concrete information about 
a possible association of achalasia of the esophagus with abnormalities of 
the anorectum. While the association of these two conditions is seemingly obvious after this study, there are several issues which require consideration and further interpretation. 
First: the occurrence of this situation in six of nine patients is 
extraordinary, leading us to question whether the patients in this group are typical of other patients with achalasia of the esophagus, in whom the 
incidence of colonic problems is markedly less common that 60-70%. Could 
the authors address this issue, providing further documentation regarding the status of the colon (i.e. calibre, size, general function). 
How do the authors reconcile the low incidence of rectal and anal 
complaints in large series of patients with achalasia of the esophagus from the Western hemisphere including (primarily) South America and North 
America. (In our own group of > 100 patients with achalasia, for example, 
we have not identified a similar patient; of course, a subclinical 
presentation may have avoided recognition). 
The aganglionosis described in this report is of intense interest, however, 
and this paper will stimulate a lot of thought and reinvestigation in 
clinics around the world. I think it is highly interesting, indeed. 
Competing interests: 
None declared. 
Reviewer's report 
 Anorectal motility in patients with achalasia of the esophegus: recognition of an Title: 
esophago-rectal syndrom 
Authors: 
Prof Ahmed A Shafik ( ashafik@ahmedshafik.org )
 1  22 Apr 2003 Version: Date: 
 Philip Donahue Reviewer: 
 A paper of considerable general medical or scientific interest Level of interest: 
 Other (see below) Advice on publication: 
Anorectal and colonic motility in patients with achalasia can be affected 
by anganglionosis, and this study provides some concrete information about 
a possible association of achalasia of the esophagus with abnormalities of 
the anorectum. While the association of these two conditions is seemingly obvious after this study, there are several issues which require consideration and further interpretation. 
First: the occurrence of this situation in six of nine patients is 
extraordinary, leading us to question whether the patients in this group are typical of other patients with achalasia of the esophagus, in whom the 
incidence of colonic problems is markedly less common that 60-70%. Could 
the authors address this issue, providing further documentation regarding the status of the colon (i.e. calibre, size, general function). 
How do the authors reconcile the low incidence of rectal and anal 
complaints in large series of patients with achalasia of the esophagus from the Western hemisphere including (primarily) South America and North 
America. (In our own group of > 100 patients with achalasia, for example, 
we have not identified a similar patient; of course, a subclinical 
presentation may have avoided recognition). 
The aganglionosis described in this report is of intense interest, however, 
and this paper will stimulate a lot of thought and reinvestigation in 
clinics around the world. I think it is highly interesting, indeed. 
Competing interests: 
None declared. 
Please review this paper.
user
Reviewer's report 
 Anorectal motility in patients with achalasia of the esophegus: recognition of an Title: 
esophago-rectal syndrom 
Authors: 
Prof Ahmed A Shafik ( ashafik@ahmedshafik.org )
 1  22 Apr 2003 Version: Date: 
 Philip Donahue Reviewer: 
 A paper of considerable general medical or scientific interest Level of interest: 
 Other (see below) Advice on publication: 
Anorectal and colonic motility in patients with achalasia can be affected 
by anganglionosis, and this study provides some concrete information about 
a possible association of achalasia of the esophagus with abnormalities of 
the anorectum. While the association of these two conditions is seemingly obvious after this study, there are several issues which require consideration and further interpretation. 
First: the occurrence of this situation in six of nine patients is 
extraordinary, leading us to question whether the patients in this group are typical of other patients with achalasia of the esophagus, in whom the 
incidence of colonic problems is markedly less common that 60-70%. Could 
the authors address this issue, providing further documentation regarding the status of the colon (i.e. calibre, size, general function). 
How do the authors reconcile the low incidence of rectal and anal 
complaints in large series of patients with achalasia of the esophagus from the Western hemisphere including (primarily) South America and North 
America. (In our own group of > 100 patients with achalasia, for example, 
we have not identified a similar patient; of course, a subclinical 
presentation may have avoided recognition). 
The aganglionosis described in this report is of intense interest, however, 
and this paper will stimulate a lot of thought and reinvestigation in 
clinics around the world. I think it is highly interesting, indeed. 
Competing interests: 
None declared. 
assistant