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Subedi D, Parajuli BR, Bista N, Rauniyar S, Dhonju K, Bhusal S, Aryal E, Adhikari D, Aryal S, Karna A. Achalasia cardia: A case report in young female. Clin Case Rep 2024; 12:e9239. [PMID: 39104735 PMCID: PMC11298990 DOI: 10.1002/ccr3.9239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/18/2024] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Key Clinical Message This case emphasizes the need for early recognition and accurate diagnosis of achalasia in young adults to avoid exacerbation of the condition and misdiagnosis as GERD. Patient outcomes and quality of life are greatly enhanced by suitable diagnostic techniques, appropriate therapy, interdisciplinary care, and comprehensive patient education along with frequent follow-ups. Abstract Achalasia results from the degeneration of inhibitory ganglion cells within the esophageal myenteric plexus and the lower esophageal sphincter (LES), leading to a loss of inhibitory neurons and resulting in the absence of peristalsis with failure of LES relaxation. Its origins are multifactorial, potentially involving infections, autoimmune responses, and genetics, with equal incidence in males and females. The hallmark symptoms include progressive dysphagia for solids and liquids, along with regurgitation, heartburn, and non-cardiac chest pain. A 22-year-old female patient initially diagnosed with gastroesophageal reflux disease (GERD) received proton pump inhibitors and antacid gel for persistent dysphagia and regurgitation. Subsequent tests including barium esophagogram and manometry indicated Type II Achalasia Cardia. The patient showed clinical improvement with relief of dysphagia, regurgitation, and heartburn symptoms after pneumatic balloon dilatation (PBD). She was advised to follow up after 6 months with upper gastrointestinal (UGI) endoscopy and manometry in the outpatient clinic for regular endoscopic surveillance as there is a risk of transformation to esophageal carcinoma. Diagnosing achalasia in young adults poses challenges due to its diverse presentation and resemblance to other esophageal disorders like GERD. Diagnosis relies on clinical symptoms and imaging studies such as barium esophagogram revealing a bird's beak appearance and esophageal manometry showing absent peristalsis. UGI endoscopy is needed to rule out malignancy. Treatment options include non-surgical approaches like medication and Botox injections, as well as surgical methods such as pneumatic balloon dilation, laparoscopic Heller myotomy, and per-oral endoscopic myotomy (POEM). The treatment options depend upon the patient's condition at presentation and their individual choices. This case report emphasizes that it is crucial to consider achalasia as a potential differential diagnosis in young adults with dysphagia, especially if conventional treatments for acid peptic disorder do not alleviate symptoms. Prompt diagnosis and appropriate management can lead to significant clinical improvement and better patient outcomes.
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Affiliation(s)
- Deepak Subedi
- Nepalese Army Institute of Health Sciences College of MedicineKathmanduNepal
| | | | - Neha Bista
- Chitwan Medical College and Teaching HospitalChitwanNepal
| | | | - Kiran Dhonju
- Sukraraj Tropical and Infectious Disease HospitalKathmanduNepal
| | | | - Egesh Aryal
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | | | | | - Ayush Karna
- Kathmandu University School of Medical SciencesDhulikhelNepal
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Forero-Vásquez BN, Yopasa-Romero JJ. Diagnóstico y manejo actual de la acalasia. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia.
Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología.
Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales.
Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes.
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Conte TM, Haddad LBDP, Ribeiro IB, de Moura ETH, DʼAlbuquerque LAC, de Moura EGH. Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial. Endosc Int Open 2020; 8:E1673-E1680. [PMID: 33140023 PMCID: PMC7584466 DOI: 10.1055/a-1261-3417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims We aimed to perform an economic evaluation of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia. Materials and methods An economic cost-utility analysis was carried out over a time horizon of 1 year. Patients with achalasia who were admitted to the gastroenterology outpatient clinic of a public tertiary referral hospital were assigned to undergo POEM or LHM. The monetary amounts were extracted from the intranet of the institution using microcosting. All costs associated with the procedure, hospitalization, clinical follow-up and resolution of therapeutic complications were included. The utility data were measured in quality-adjusted life years (QALYs), which were estimated from the scores of a quality-of-life questionnaire. Results Forty patients (20 POEM patients and 20 LHM patients) were included. The final cost associated with POEM and LHM was US$ 2,619.19 ± 399.53 and US$ 1,696.44 ± 412.21, respectively ( P < 0.001). However, the QALYs in the POEM group (0.434 ± 0.215 vs 0.332 ± 0.222, P = 0.397) were slightly higher than those in the LHM group. The incremental cost-utility ratio (ICUR) suggested that an additional US$ 9,046.41/QALY gained was required when using POEM. Conclusion For the treatment of achalasia in the public health system, POEM appears to be more cost-effective than LHM in the short term.
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Affiliation(s)
| | - Luciana Bertocco de Paiva Haddad
- Department of Transplantation, Gastroenterology Division, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Endoscopy, Gastroenterology Division, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | | | - Luiz Augusto Carneiro DʼAlbuquerque
- Department of Transplantation, Gastroenterology Division, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
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Yoon HJ, Lee JE, Jung DH, Park JC, Youn YH, Park H. Morphologic Restoration After Peroral Endoscopic Myotomy in Sigmoid-type Achalasia. J Neurogastroenterol Motil 2020; 26:67-73. [PMID: 31869868 PMCID: PMC6955197 DOI: 10.5056/jnm19144] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/17/2019] [Accepted: 11/25/2019] [Indexed: 01/30/2023] Open
Abstract
Background/Aims Achalasia is a chronic, progressive motility disorder of the esophagus. The sigmoid-type achalasia is an advanced stage of achalasia characterized by severe dilatation and tortuous angulation of the esophageal body. Peroral endoscopic myotomy (POEM) has been reported to provide excellent clinical outcomes for achalasia, including the sigmoid type, but the restoration of esophageal morphology and function remain poorly described. The aim of our study is to investigate esophageal restoration after POEM for sigmoid-type achalasia. Methods From 98 patients with achalasia who underwent POEM in the Yonsei University Health System from 2013 to 2018, we recruited 13 patients with sigmoid-type achalasia (7 male; mean age 53.3 years) and assessed morphological and manometric changes in the esophagus. Results Clinical success (Eckardt score < 3) was achieved in all cases. After POEM, the average angle of esophageal tortuosity became more obtuse (91.5° vs 114.6°, P = 0.046), esophageal body diameter decreased (67.6 vs 49.8 mm, P = 0.002), and esophagogastric junction opening widened (6.4 vs 9.5 mm, P = 0.048). Patients whose esophageal tortuosity did not improve had longer durations of symptoms than patients with improvement (80.2 vs 636 months, P < 0.001). An absence of peristalsis was observed in all patients pre- and post-POEM. Conclusions POEM resulted in excellent clinical outcomes and morphologic improvement in sigmoid-type achalasia. These results suggest that the improvement of esophageal tortuosity through POEM reflects a reduced esophageal burden.
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Affiliation(s)
- Hong Jin Yoon
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeung Eun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Prieto RG, Prieto JE, Casas F, Ballén H. Acalasia, una visión actual. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Pesce M, Magee C, Holloway RH, Gyawali CP, Roman S, Pioche M, Savarino E, Quader F, Sarnelli G, Sanagapalli S, Bredenoord AJ, Sweis R. The treatment of achalasia patients with esophageal varices: an international study. United European Gastroenterol J 2019; 7:565-572. [PMID: 31065374 DOI: 10.1177/2050640619838114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/22/2019] [Indexed: 01/10/2023] Open
Abstract
Background Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk. Methods Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group. Results Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 ± 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 non-cirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation. Conclusion This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.
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Affiliation(s)
- M Pesce
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,University of Naples "Federico II", Naples, Italy
| | - C Magee
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
| | | | - C P Gyawali
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - S Roman
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - M Pioche
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | | | - F Quader
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - G Sarnelli
- University of Naples "Federico II", Naples, Italy
| | - S Sanagapalli
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,St. Vincent's Hospital Sydney, Sydney, Australia
| | - A J Bredenoord
- Division of Gastroenterology and Hepatology, Amsterdam Medical Centre, Amsterdam, Netherlands
| | - R Sweis
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
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Döhla M, Leichauer K, Gockel I, Niebisch S, Thieme R, Lundell L, Schumacher J, Becker J, Rieker RJ, Hartmann A, Vieth M, Veits L. Characterization of esophageal inflammation in patients with achalasia. A retrospective immunohistochemical study. Hum Pathol 2019; 85:228-234. [DOI: 10.1016/j.humpath.2018.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/01/2018] [Indexed: 01/15/2023]
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The Role of Botulinum Toxin Injections for Esophageal Motility Disorders. ACTA ACUST UNITED AC 2018; 16:528-540. [DOI: 10.1007/s11938-018-0212-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Newberry C, Vajravelu RK, Pickett-Blakely O, Falk G, Yang YX, Lynch KL. Achalasia Patients Are at Nutritional Risk Regardless of Presenting Weight Category. Dig Dis Sci 2018; 63:1243-1249. [PMID: 29468378 DOI: 10.1007/s10620-018-4985-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/14/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Achalasia is an esophageal motor disorder that leads to swallowing dysfunction and weight loss. Nutritional risk in achalasia patients is not well defined. AIMS The aims of this study were to define baseline body mass index (BMI), changes in weight, and nutritional risk over time in a large cohort of achalasia patients. METHODS This was a retrospective cohort study of achalasia patients at a tertiary care center with documented BMI, symptom severity as per Eckardt score, and nutritional risk assessment as per the Malnutrition Universal Screening Tool, which considers BMI, degree of recent weight loss, and acuity of disease. RESULTS Among the 337 patients presenting for achalasia management, 179 had confirmed disease. Upon presentation 69.8% of patients were classified as overweight or obese. Using the Malnutrition Universal Screening Tool, we found 50% of patients to be at moderate or high risk for malnutrition at presentation. Eckardt score (OR 1.15, 95% CI 1.05-1.26), duration of disease (OR for each additional month 1.04, 95% CI 1.01-1.08), and female gender (OR 1.76, 95% CI 1.02-3.03) were independent predictors of increased risk for malnutrition. Nutrition risk score decreased after therapy in 93.3% of patients. CONCLUSIONS Despite a high prevalence of overweight and obese status in achalasia patients, many are at risk of developing nutritional complications secondary to rapid weight loss. This risk frequently resolves post-treatment. Regardless of baseline BMI, we recommend all patients undergo nutritional assessment to identify high-risk patients who may benefit from dietary intervention and expedited therapy.
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Affiliation(s)
- Carolyn Newberry
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA.
| | - Ravy K Vajravelu
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Octavia Pickett-Blakely
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Yu Xiao Yang
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 733 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Kristle L Lynch
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
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Benedict JJ, Golas AA, Richter JE, Velanovich V. Health-Related Quality of Life and Physiological Outcomes of Peroral Endoscopic Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2017; 27:778-783. [PMID: 28657822 DOI: 10.1089/lap.2017.0087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has gained acceptance as a treatment for achalasia. The aim of this study was to assess symptomatic, quality of life (QoL), and physiological outcomes of POEM using standardized methods. MATERIALS AND METHODS Patients who were planned to undergo POEM were evaluated pre- and postoperatively with timed barium esophagogram (TBE), high-resolution manometry (HRM), the achalasia symptom questionnaire (ASQ) (best score 10, worst score 31), and the short form (SF)-36 (best score 100, worst score 0). Nine patients completed postoperative HRM, TBE, and 48 hours esophageal pH monitoring. A P-value of <.05 was considered statistically significant. RESULTS A total of 34 of 37 patients completed the POEM procedure. There was improvement in the ASQ scores and in QoL. HRM integrated relaxation pressures (IRPs) improved from 31.4 ± 10.8 mmHg preoperatively to 12.3 ± 6.7 mmHg postoperatively, and lower esophageal sphincter pressure (LESP) improved from 49.1 ± 16.9 mmHg preoperatively to 23.1 ± 9.4 mmHg postoperatively. Of the 7 patients who were evaluated with 48-hour pH monitoring postoperatively, 5 patients (71%) demonstrated pathological reflux with an average Demeester score of 23.1 ± 19.1. There was a negative linear correlation between LESP change and Demeester scores (r = -0.7, P = .03). CONCLUSION The POEM procedure significantly improves achalasia-related symptoms and improves social functioning. Physiologically, there is reduction in both IRP and LESP. Postoperative pathological reflux is correlated with LESP reduction.
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Affiliation(s)
- Jacob J Benedict
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Adam A Golas
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Joel E Richter
- 2 Division of Gastroenterology, University of South Florida Morsani College of Medicine , Tampa, Florida.,3 Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Vic Velanovich
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida.,3 Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine , Tampa, Florida
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