An epidemiological study of achalasia among the South Asian population of Leicester, 1986-2005

Factors associated with peroral endoscopic myotomy for achalasia outcomes: systematic review and meta-analysis

BACKGROUND

Peroral endoscopic myotomy (POEM) is an emerging effective treatment for achalasia. However, a significant proportion of patients do not respond well to the treatment. After over a decade of clinical practice, potential risk factors associated with POEM failure have been identified. This meta-analysis aimed to summarize the evidence of risk factors for POEM failure.

METHODS

A systematic literature search was conducted on PubMed, Embase, Web of Science, and Cochrane Library from inception to June 10th, 2022. We included English studies that reported POEM outcomes in achalasia patients and identified risk factors for POEM failure. Relevant information was extracted and analyzed using fixed- or randomized-effect models to pool the effect size.

RESULTS

A total of 27 studies comprising 9371 patients with achalasia were included in this review. The pooled failure rate was 8% (90% CI 7%-10%). We identified sigmoid esophagus (OR 1.90, 95% CI 1.45-2.47), type I achalasia (OR 1.30, 95% CI 1.04-1.63), and type III achalasia (OR 1.26, 95% CI 0.89-1.78) were associated with a worse clinical response. Conversely, type II achalasia was associated with a better response (OR 0.59, 95% CI 0.47-0.75). Prior treatment with Heller myotomy (OR 5.75, 95% CI 3.97-8.34) and prior balloon dilation (OR 1.18, 95% CI 1.07-1.29) were also associated with a higher risk of clinical failure.

CONCLUSION

Our meta-analysis results demonstrated that sigmoid esophagus, manometric achalasia subtype, and prior treatment were associated with POEM failure. This information could be used to guide treatment decisions and improve the success rate of POEM in achalasia patients.

Development and Validation of a National US Achalasia Cohort: The Veterans Affairs Achalasia Cohort (VA-AC)

BACKGROUND & AIMS

Achalasia is an esophageal motility disorder associated with significant morbidity, yet achalasia-associated risk factors and outcomes are not well-characterized. Our aim was to establish a national cohort of individuals with achalasia, utilizing Veterans Health Administration (VHA) data.

METHODS

We iteratively developed combinations of International Classification of Diseases and Current Procedural Terminology code algorithms to validate an approach for identifying achalasia cases. We assessed algorithm accuracy for achalasia diagnosis through manual chart review of candidate achalasia cases and candidate non-achalasia controls. The prespecified end point chosen to establish algorithm performance success was achieving a 1-sided 95% confidence lower bound for a positive predictive value >85% for a random sample of 100 candidate achalasia cases. Once adequate performance was validated, we queried national VHA data to establish and characterize a cohort of individuals diagnosed with achalasia between 1999 and 2020.

RESULTS

Three rounds of algorithm modification and validation were conducted to achieve the prespecified performance endpoint. In the final round, a combination of 3 or more International Classification of Diseases codes for achalasia in the subject's lifetime and a Current Procedural Terminology code for esophageal manometry achieved an observed 94% positive predictive value (1-sided 95% confidence lower bound of 88.5%) for identifying achalasia. Applying the algorithm to national VHA data identified a cohort of 2100 individuals with achalasia, with a median age 65 years and who were 93% male.

CONCLUSIONS

Using a rigorous validation approach, we established a national cohort of 2100 individuals with achalasia within the VHA, one of the largest established to date. This cohort can be utilized to study risk factors for achalasia and outcomes over time.

Reconstruction of the Gastro-esophageal Junction Based on Ultramill Imaging for Biomechanical Analysis

The gastro-esophageal junction (GEJ) regulates the entry of food into the stomach and prevents reflux of acidic gastric contents into the lower esophagus. This is achieved through multiple mechanisms and the maintenance of a localized high-pressure zone. Diseases of the GEJ typically involve impairments to its muscular functions and often are accompanied by symptoms of reflux, heartburn, and dysphagia. This study aimed to develop a finite element-based model from a unique human cadaver GEJ data reconstructed from an ultramill imaging setup. A pipeline was developed to generate a mesh from an input stack of images. The anatomy of the model was compared to an existing Visible Human finite element GEJ model. Biomechanical simulations were also performed on both models using loading steps of differing levels of calcium to model different levels of contraction. It was found that the ultramill GEJ model is shorter than the Visible Human model (31 vs 48.3 mm), as well as producing lower pressure (1.35 vs 4.36 kPa). The model will be used to investigate detailed pressure development in the GEJ during swallowing under realistic loading conditions. Clinical Relevance - The modeling of the GEJ would allow further insights into pressure influencing factors and aid in the development and testing of treatments.

Different Clinical Features of Idiopathic Achalasia in Various Countries

Idiopathic achalasia is a motility disorder affecting the lower esophageal sphincter. Dysphagia is a hallmark symptom, but patients may exhibit other symptoms. The aim of this review is to compare achalasia symptoms globally. PubMed and Google Scholar were filtered from 1952–2021 with the search terms achalasia, epidemiology, diet, countries, and genetics. A total of 14 articles addressed demographics, symptom profiles, genetics, and diagnosis criteria amongst 2463 patients. Data on countries’ climate and diet were obtained through Arc Geographic Information System (GIS) and Our World in Data. Countries were grouped by similar climate zones and diets. Achalasia symptoms varied by region. In West Africa, patients exhibit parotid swelling, anemia, and dehydration; diminished appetite in East Asia; dysphagia and weight loss in West Asia and Europe; respiratory symptoms, reflux, and retrosternal pain in North America; and vomiting in Southern Asia. Weighted percentages of dietary oils/fats were (24.3%) in North America, Western Asia (17.8%); Europe (17.7%); East Asia (17.6%); West Africa (14.7%); Southern Asia (13.8%); North Africa (12.4%); Northeast Africa (10.1%). Conditions such as Down Syndrome and Triple A syndrome are associated with achalasia. There was no correlation for achalasia presentation and climate zones. Achalasia symptoms are likely multifactorial. Diet, genetics, and environmental factors may play significant roles.

Frequency and clinical characteristics of special types of achalasia in Japan: A large-scale, multicenter database study

BACKGROUND AND AIM

Achalasia is a rare disease, with an incidence of one in 100 000. Genetic factors and autoimmune involvement have been reported in its etiology, and their involvement is strongly suspected, especially in patients with familial achalasia and those with comorbid hereditary or autoimmune diseases. However, these special types of achalasia are rare, and their frequency and clinical characteristics remain unclear.

METHODS

This retrospective, multicenter cohort study included Japanese patients with a diagnosis of achalasia, treated between 2010 and 2019 across six tertiary centers in Japan. The frequency and clinical characteristics of special types of achalasia, namely, familial achalasia, achalasia with a comorbid hereditary disease, and achalasia with a comorbid autoimmune disease, were retrospectively investigated using a large-scale multicenter database.

RESULTS

During the study period, 1115 patients were treated for achalasia at six tertiary centers. Familial achalasia, achalasia with a comorbid hereditary disease, and achalasia with a comorbid autoimmune disease occurred in 7 (0.63%), 11 (0.99%), and 27 (2.4%) patients, respectively. Familial achalasia had a slightly younger age of onset (37.6 ± 12.1 years old) and a higher incidence in male patients (six patients; 85.7%). Down's syndrome was the most common hereditary comorbidity, and thyroid disease was the most common autoimmune comorbidity.

CONCLUSIONS

We clarified the frequency and clinical characteristics of special types of achalasia. Although special types of achalasia are rare, these comorbidities should be considered when treating patients with achalasia.

Achalasia and acromegaly: co-incidence of these diseases or a new syndrome?

BACKGROUND

Acromegaly is a disorder associated with hypersecretion of growth hormone, most usually caused by a pituitary adenoma. Dysmotility of the gastrointestinal tract has been reported in acromegalic patients. Achalasia is a disorder characterized by aperistalsis of the oesophagus with incomplete lower oesophageal sphincter relaxation and whose aetiology remains unknown. Mutations in some genes have previously been associated with the development of acromegaly or achalasia. The study aims were to analyse mutations in selected genes in a woman having both of these diseases, to identify their aetiological factors, and to suggest explanations for the co-incidence of acromegaly and achalasia.

METHODS AND RESULTS

A female patient with acromegaly, achalasia, and a multinodular thyroid gland with hyperplastic colloid nodules underwent successful treatment of achalasia via laparoscopic Heller myotomy, a thyroidectomy was performed, and the pituitary macroadenoma was surgically excised via transnasal endoscopic extirpation. Germline DNA from the leukocytes was analysed by sequencing methods for a panel of genes. No pathogenic mutation in AAAS, AIP, MEN1, CDKN1B, PRKAR1A, SDHB, GPR101, and GNAS genes was found in germline DNA. The somatic mutation c.601C>T/p.R201C in the GNAS gene was identified in DNA extracted from a tissue sample of the pituitary macroadenoma.

CONCLUSIONS

We here describe the first case report to our knowledge of a patient with both acromegaly and achalasia. Association of acromegaly and soft muscle tissue hypertrophy may contribute to achalasia's development. If one of these diagnoses is determined, the other also should be considered along with increased risk of oesophageal and colorectal malignancy.

SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia.

RESULTS

The panel agreed on 4 recommendations for adults and children with achalasia.

CONCLUSIONS

Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.

Postoperative pregnancy in female achalasia patients: Report of three cases

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The relationship between symptoms recurrence and postoperative pregnancy after surgery in achalasia patients remains unclear.

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This study retrospectively investigated 3 patients who became pregnant after surgery.

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All 3 patients who became pregnant after achalasia surgery had temporary symptom recurrence.

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However, these patients could delivery without any treatment, and their symptoms improved immediately after delivery.

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The pregnancy may have negative impact on temporary symptom and recurrence in achalasia patients after surgery.

Background

The aggravation of symptoms in female patients with esophageal achalasia has been sporadically reported to be associated with pregnancy. However, the relationship between symptoms recurrence and postoperative pregnancy after radical surgery remains unclear.

Case presentation

There were 3 female achalasia patients who became pregnant after surgery between 1994 and 2018. Patient #1, #2 and #3 were 32, 27 and 25 years old, respectively. The main symptom was vomiting in #1, chest pain in #2, dysphagia in #3, the Eckardt score was 12, 9 and 7, respectively. The classification of achalasia was St grade Ⅱ in #1-2, St grade Ⅲ in #3. Laparoscopic Heller-Dor was underwent in all patients, there were no intraoperative and postoperative complications, and the symptoms improved in these patients. The Eckardt scores decreased to 2, 3 and 1, respectively. Each patient became pregnant 36, 24 and 46 months after surgery, and symptoms recurred during pregnancy in all patients. The Eckardt scores increased to 4, 5 and 4. These patients were followed without oral administration due to the risk of teratogenicity, and the pregnancies progressed smoothly. Healthy babies were delivered vaginally at 38–41 weeks. The symptoms in all patients were immediately improved after delivery, and there was no recurrence of symptoms thereafter.

Conclusions

This case report showed that female patients who became pregnant after achalasia surgery had temporary symptom relapse during pregnancy. It was possible to continue pregnancy and deliver without treatment, and symptoms spontaneously improved immediately after delivery.

Application of botulinum toxin in pregnancy and its impact on female reproductive health

Introduction: Botulinum toxin (BoNT) is a protein secreted by the anaerobic Gram-negative bacterium Clostridium botulinum. Among the seven known subtypes, type A is the most commonly used in women to treat diseases. It primarily blocks presynaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis; thus, it is suitable for treating dystonia and other systemic diseases. BoNT is used widely for treating diseases that persist throughout, and may worsen during, pregnancy, such as cervical dystonia and achalasia. Thus, it is important to investigate whether BoNT injection during pregnancy causes side effects in pregnant women, fetuses, or newborns.Areas covered: This review highlights the efficiency and safety of BoNT injection in pregnancy. and assessed current literature with respect to the use of BoNT for disease treatment during pregnancy.Expert opinion: BoNT injection does not increase the risk of complications in pregnant women and fetuses. However, the use of BoNT to treat disease during pregnancy requires fully informed consent from patients. In addition, further research is needed to determine how to reduce the side effects of BoNT injection during pregnancy (e.g., by improving drug composition, or adjusting the amount of BoNT or the injection interval).

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Esophageal achalasia and pregnancy: own observations in 43 patients and a review of the literature

INTRODUCTION

Little is known concerning the interaction of achalasia and pregnancy and about an optimal time and type for treatment. Achalatic women of our collective of patients with at least one pregnancy in their history resulting in confinement or miscarriage were invited for a structured interview.

MATERIALS AND METHODS

43 of 109 female patients were included. Questionnaire contained questions on symptoms, type of symptoms, whether patients could link a specific event with outbreak of disease. Date of primary diagnosis and individual therapies were double checked against our documentation as well as duration of complaints and kind of therapy. Patients were asked about their obstetric history, whether and how symptoms had changed, and during which pregnancy week symptoms have occurred. Temporal correlation of the diagnosis of achalasia and pregnancy was investigated.

RESULTS

There was no relationship between pregnancy and onset of achalasia. Risk of subfertility, undernourishment, premature birth, or miscarriage does not seem to be increased in achalasia. Health condition often worsened significantly during pregnancy, mainly in the first trimester and particularly in the untreated patients.

CONCLUSIONS

It is advisable to clarify the diagnosis if symptoms suspicious of an achalasia are present before a planned pregnancy. In case of manifest achalasia, surgical treatment should be performed before pregnancy and the improvement in the state of health should be anticipated, as, otherwise, a considerable deterioration of the symptoms during pregnancy may occur. Scientific impact of our observations is very limited and prospective clinical trials are required.

Incidence and costs of achalasia in The Netherlands

BACKGROUND

Recent reports show increasing incidence of achalasia in some populations. The aim of this study was to estimate incidence, prevalence, and healthcare costs of achalasia in a large cohort in The Netherlands.

METHODS

Data were obtained from the largest Dutch healthcare insurance company (±4.4 million insured). Adult achalasia patients were identified between 2006 and 2014 when having an achalasia diagnosis code registered. A total of 907 achalasia patients were identified and included in our database, along with 9068 control patients (non-achalasia patients), matched by age and gender.

KEY RESULTS

The mean incidence over the 9-year period was 2.2 per 100 000 persons and the mean prevalence was 15.3 per 100 000 persons. Mean age of achalasia patients was 54 (range 18-98) years. Male to female ratio was 1:1. Socio-economic status distribution was similar in achalasia patients and controls. Prior to the diagnosis, 74% of achalasia patients received proton pump inhibitors and 26% received anti-emetic medication. The first year after diagnosis median total direct medical costs of achalasia patients were €2283 (IQR 969-3044) per year. Patients above the 90th percentile of €4717 were significantly older than other patients below the 90th percentile (mean age 63 vs 57); P = .005.

CONCLUSION & INFERENCES

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.

Focal achalasia - case report and review of the literature

Esophageal achalasia is a primary smooth muscle motility disorder specified by aperistalsis of the tubular esophagus in combination with a poorly relaxing and occasionally hypertensive lower esophageal sphincter (LES). These changes occur secondary to the destruction of the neural network coordinating esophageal peristalsis and LES relaxation (plexus myentericus). There are limited data on segmental involvement of the esophagus in adults.

We report on the case of a 54-year-old man who presented initially with complete aperistalsis limited to the distal esophagus. After a primary good response to BoTox-infiltration of the distal esophagus the patient relapsed two years later. The manometric recordings documented now a progression of the disease with a poorly relaxing hypertensive lower esophageal sphincter and complete aperistalsis of the tubular esophagus (type III achalasia according to the Chicago 3.0 classification system).

This paper also reviews diagnostic findings (including high resolution manometry, CT scan, barium esophagram, upper endoscopy and upper endoscopic ultrasound data) in patients with achalasia and summarizes the therapeutic options (including pneumatic balloon dilatation, botulinum toxin injection, surgical or endoscopic myotomy).

Incidence of Achalasia in South Australia Based on Esophageal Manometry Findings

BACKGROUND & AIMS

Achalasia is a disorder of esophageal motility with a reported incidence of 0.5 to 1.6 per 100,000 persons per year in Europe, Asia, Canada, and America. However, estimates of incidence values have been derived predominantly from retrospective searches of databases of hospital discharge codes and personal communications with gastroenterologists, and are likely to be incorrect. We performed a cohort study based on esophageal manometry findings to determine the incidence of achalasia in South Australia.

METHODS

We collected data from the Australian Bureau of Statistics on the South Australian population. Cases of achalasia diagnosed by esophageal manometry were identified from the 3 adult manometry laboratory databases in South Australia. Endoscopy reports and case notes were reviewed for correlations with diagnoses. The annual incidence of achalasia in the South Australian population was calculated for the decade 2004 to 2013. Findings were standardized to those of the European Standard Population based on age.

RESULTS

The annual incidence of achalasia in South Australia ranged from 2.3 to 2.8 per 100,000 persons. The mean age at diagnosis was 62.1 ± 18.1 years. The incidence of achalasia increased with age (Spearman rho, 0.95; P < .01). The age-standardized incidence ranged from 2.1 (95% CI, 1.8-2.3) to 2.5 (95% CI, 2.2-2.7).

CONCLUSIONS

Based on a cohort study of esophageal manometry, we determined the incidence of achalasia in South Australia to be 2.3 to 2.8 per 100,000 persons and to increase with age. South Australia's relative geographic isolation and the population's access to manometry allowed for more accurate identification of cases than hospital code analyses, with a low probability of missed cases.

Incidence and Prevalence of Achalasia in Central Chicago, 2004-2014, Since the Widespread Use of High-Resolution Manometry

BACKGROUND & AIMS

Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63 per 100,000 persons per year and from 1.8 to 12.6 per 100,000 persons per year, respectively. This study aimed to reconcile these low values with findings from a major referral center, in central Chicago (which began using high-resolution manometry in 2004 and used it in all clinical studies since 2005), and has determined the incidence and prevalence of achalasia to be much greater.

METHODS

We collected data from the Northwestern Medicine Enterprise Data Warehouse database (tertiary care setting) of adults residing in Chicago with an encounter diagnosis of achalasia from 2004 through 2014. Patient files were reviewed to confirm diagnosis and residential address. US Census Bureau population data were used as the population denominator. We assumed that we encountered every incident case in the city to calculate incidence and prevalence estimates. Data were analyzed for the city at large and for the 13 zip codes surrounding the Northwestern Memorial Hospital (NMH), the NMH neighborhood.

RESULTS

We identified 379 cases (50.9% female) that met the full inclusion criteria; of these, 246 were incident cases. Among these, 132 patients resided in the NMH neighborhood, 89 of which were incident cases. Estimated yearly incidences were stable over the study period, ranging from 0.77 to 1.35 per 100,000 citywide (average, 1.07 per 100,000) and from 1.41 to 4.60 per 100,000 in the NMH neighborhood (average, 2.92 per 100,000). The corresponding prevalence values increased progressively, from 4.68 to 14.42 per 100,000 citywide and from 15.64 to 32.58 per 100,000 in the NMH neighborhood.

CONCLUSIONS

The incidence and prevalence of achalasia in central Chicago diagnosed using state-of-the-art technology and diagnostic criteria are at least 2- to 3-fold greater than previous estimates. Additional studies are needed to determine the generalizability of these data to other regions.

Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature

INTRODUCTION

Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM.

METHODS

The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible.

RESULTS

The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24).

CONCLUSION

POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.

The HLA-DQβ1 insertion is a strong achalasia risk factor and displays a geospatial north-south gradient among Europeans

Idiopathic achalasia is a severe motility disorder of the esophagus and is characterized by a failure of the lower esophageal sphincter to relax due to a loss of neurons in the myenteric plexus. Most recently, we identified an eight-amino-acid insertion in the cytoplasmic tail of HLA-DQβ1 as strong achalasia risk factor in a sample set from Central Europe, Italy and Spain. Here, we tested whether the HLA-DQβ1 insertion also confers achalasia risk in the Polish and Swedish population. We could replicate the initial findings and the insertion shows strong achalasia association in both samples (Poland P=1.84 × 10(-04), Sweden P=7.44 × 10(-05)). Combining all five European data sets - Central Europe, Italy, Spain, Poland and Sweden - the insertion is achalasia associated with Pcombined=1.67 × 10(-35). In addition, we observe that the frequency of the insertion shows a geospatial north-south gradient. The insertion is less common in northern (around 6-7% in patients and 2% in controls from Sweden and Poland) compared with southern Europeans (~16% in patients and 8% in controls from Italy) and shows a stronger attributable risk in the southern European population. Our study provides evidence that the prevalence of achalasia may differ between populations.

Treatment of esophageal motility disorders based on the chicago classification

OPINION STATEMENT

The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.

Achalasia in Korea: an epidemiologic study using a national healthcare database

Owing to the rarity of the disease, epidemiologic information on achalasia is limited. This study aimed to investigate the epidemiology and treatment patterns of achalasia in the population of Korea using a national healthcare database. The diagnostic code K22.0 of the International Classification of Diseases was used to identify cases of achalasia between 2007 and 2011. Treatment modalities for achalasia were identified using the electronic data interchange codes Q7642 or Q7641 for balloon dilation and QA421 or QA422 for esophago-cardiomyotomy. A total of 3,105 patients with achalasia (1,447 men; mean age, 52.5 yr) were identified between 2007 and 2011, indicating a prevalence of 6.29/100,000 (95% confidence interval [CI], 4.94-7.66) during this 5-yr period. A total of 191 incident cases of achalasia (82 men; mean age, 49.5 yr), which were not diagnosed as achalasia in the previous 4 yr, were detected in 2011, indicating an incidence of 0.39/100,000 (95% CI, 0.15-0.63) for that year. During the study period, balloon dilation therapy was performed a total of 975 times in 719 patients, and surgical esophago-cardiomyotomy was performed once per patient in 17 patients. This is the first population-based epidemiologic study of achalasia in Korea.

Achalasia

Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.

Achalasia: A review of clinical diagnosis, epidemiology, treatment and outcomes

Achalasia is a neurodegenerative motility disorder of the oesophagus resulting in deranged oesophageal peristalsis and loss of lower oesophageal sphincter function. Historically, annual achalasia incidence rates were believed to be low, approximately 0.5-1.2 per 100000. More recent reports suggest that annual incidence rates have risen to 1.6 per 100000 in some populations. The aetiology of achalasia is still unclear but is likely to be multi-factorial. Suggested causes include environmental or viral exposures resulting in inflammation of the oesophageal myenteric plexus, which elicits an autoimmune response. Risk of achalasia may be elevated in a sub-group of genetically susceptible people. Improvement in the diagnosis of achalasia, through the introduction of high resolution manometry with pressure topography plotting, has resulted in the development of a novel classification system for achalasia. This classification system can evaluate patient prognosis and predict responsiveness to treatment. There is currently much debate over whether pneumatic dilatation is a superior method compared to the Heller’s myotomy procedure in the treatment of achalasia. A recent comparative study found equal efficacy, suggesting that patient preference and local expertise should guide the choice. Although achalasia is a relatively rare condition, it carries a risk of complications, including aspiration pneumonia and oesophageal cancer. The risk of both squamous cell carcinoma and adenocarcinoma of the oesophagus is believed to be significantly increased in patients with achalasia, however the absolute excess risk is small. Therefore, it is currently unknown whether a surveillance programme in achalasia patients would be effective or cost-effective.

Epidemiology and practice patterns of achalasia in a large multi-centre database

BACKGROUND

Due to its rarity, achalasia remains a difficult disease to study.

AIMS

To describe the epidemiology of achalasia and practice patterns in its endoscopic management, utilising patient records from a large national database of endoscopic procedures.

METHODS

The Clinical Outcomes Research Initiative maintains a database of endoscopic procedures in diverse clinical practices. The data from 89 endoscopy practices distributed throughout the US during 2000-2008 were used to analyse the characteristics and therapy of patients with achalasia.

RESULTS

Among 521,497 upper endoscopies during the study period, we identified 896 patients with achalasia. Compared with the entirety of all other endoscopic diagnoses, achalasia was more common in men than in women (OR=1.39, CI 1.22-1.59), but similar among nonwhites and whites (OR=0.87, CI 0.74-1.03). Relatively, more achalasia patients were treated at university than at community practices (OR=1.52, CI 1.30-1.78). Botox injection was most frequently used as first choice of endoscopic therapy in 41%, followed by balloon dilation in 21%, Savary dilation in 20%, Maloney dilation in 10%, Rigiflex in 4% and other modalities in 4% of patients. One quarter of achalasia patients treated endoscopically underwent a repeat therapy about every 14 months.

CONCLUSIONS

Botox has become the primary choice of initial endoscopic therapy in achalasia. Despite their partial deviation from guidelines and recommendations, these endoscopic patterns reflect the current clinical practice in the United States.

Esophageal achalasia in the Veneto region: epidemiology and treatment. Epidemiology and treatment of achalasia

INTRODUCTION

Achalasia is a rare esophageal motility disorder, incurable but amenable to palliative treatments to relieve dysphagia. Given the rarity of the disease, there is a paucity of data from population-based studies on incidence and outcome of the two treatments most commonly used in clinical practice, i.e., endoscopic pneumatic dilation (PD) and surgical myotomy (SM).

MATERIALS AND METHODS

A retrospective longitudinal study was conducted on the Veneto region, in north-eastern Italy. All patients with achalasia as their primary diagnosis between 2001 and 2005 were identified and their demographics and treatment details obtained.

RESULTS

The overall incidence of achalasia was 1.59 cases/100,000/year. Achalasia patients were mainly seen at University Hospitals. Fifty-five percent of the patients received treatment, 23.3% SM and 31.8% PD. The cumulative risk of any subsequent intervention for achalasia was 20% in treated patients (29.7% in patients treated primarily with PD and 4% in patients treated with SM first).

DISCUSSION

The epidemiology of achalasia in the Veneto Region is in line with the situation reported elsewhere and did not change between 2001 and 2005. Achalasia patients are mostly seen at University Hospitals. We observed a greater risk of subsequent intervention for patients previously treated with PD compared with SM.

Achalasia: incidence, prevalence and survival. A population-based study

BACKGROUND

Studies of achalasia epidemiology are important as they often yield new insights into disease etiology. In this study, our objective was to carry out the first North American population-based study of achalasia epidemiology using a governmental administrative database.

METHODS

All residents in the province of Alberta, Canada receive universal healthcare coverage as a benefit. The provincial health ministry, Alberta Health and Wellness, maintains a central stakeholder database of patient demographic information and physician billing claims. We defined an achalasia case as a billing claim submitted for the years 1996-2007 with an ICD-9-CM code of 530.0 or 530 and a Canadian Classification of Procedure treatment code of 54.92A (endoscopic balloon dilation) or 54.6 (esophagomyotomy). A preliminary validation study of the case definition demonstrated a sensitivity of 85% and specificity of 99% for known cases and controls.

KEY RESULTS

A total of 463 achalasia cases were identified from 1995 to 2008 (59.6% males). Mean age at diagnosis was 53.1 years. In 2007, the achalasia incidence was 1.63/100,000 (95% CI 1.20, 2.06) and the prevalence was 10.82/100,000 (95% CI 9.70, 11.93). We observed a steady increase in the overall prevalence rate from 2.51/100,000 in 1996 to 10.82/100,000 in 2007. Survival of achalasia cases was significantly less than age-sex matched population controls (P < 0.0001).

CONCLUSIONS & INFERENCES

Using a population-based approach, the incidence and prevalence of treated achalasia is 1.63/100,000 and 10.82/100,000, respectively. The disease appears to have a stable incidence but a rising prevalence. Survival of achalasia cases is significantly less than age-matched healthy controls.

Hospitalization for achalasia in the United States 1997-2006

BACKGROUND AND AIMS

The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) was used to study the demographic characteristics of achalasia patients.

METHODS

HCUP data from 1997 to 2006 were stratified by categories pertaining to patient demographics, such as age, sex, race, income, residence in metropolitan area, and region of the United States, as well as categories pertaining to hospital characteristics, such teaching status, location, and bed size. The distributions of inpatients among different categories were compared between achalasia and all other diagnoses, using odds ratios and their 95% confidence intervals for comparison.

RESULTS

The annual hospitalization rates of achalasia revealed a clear-cut age-dependent rise between the youngest age group less than 18 years old (0.25/100,000) and the oldest age group over 85 years old (37.35/100,000). Between 1997 and 2007, the rates of hospitalization remained largely unchanged for all age groups alike. Achalasia was equally distributed among men and women and among various ethnic groups. Compared with other diagnoses, achalasia was more frequent among hospitalized patients from zip codes associated with a higher average income (1.26, 1.23-1.29), living in metropolitan areas (1.12, 1.09-1.15), and living in the northeast region of the United States (1.27, 1.25-1.30). Achalasia patients were mostly seen in large hospitals (1.22, 1.19-1.26), teaching hospitals (1.73, 1.70-1.76), and hospitals located in metropolitan areas (1.15, 1.14-1.15).

CONCLUSIONS

With exception of its striking age-dependence, the epidemiology of achalasia does not reveal any clues about its yet unsolved etiology.