Changing Trends in Age, Gender, Racial Distribution and Inpatient Burden of Achalasia

Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

Challenges in Diagnosis and Treatment of Achalasia Cardia in Uganda: A Case Report of an Adolescent Female Presenting With Dysphagia

Background: Our case highlights the challenges in diagnosing and managing achalasia cardia, particularly in resource-limited settings and more so in adolescents who fall outside of the typical age range. Case Presentation: We present a case of an 18-year-old female from Uganda who was admitted with a 6-month history of progressive dysphagia, weight loss, and postprandial vomiting. Diagnosis of achalasia cardia was confirmed via endoscopy and barium swallow. Heller cardiomyotomy via open transthoracic approach was performed, but she developed an esophageal perforation, which was successfully managed with repeat thoracotomy and esophageal repair. Complete resolution of achalasia symptoms was achieved at a 5-month follow-up. Conclusion: This case highlights the importance of maintaining a high index of clinical suspicion, especially in young patients, and the significance of informed consent prior to initiating treatment. Additionally, it emphasizes the importance of early recognition of treatment-related complications, such as esophageal perforation, as key to prompt management and improved patient outcomes.

Helping the medicine go down: the role of the healthcare professional in a young person's experience of achalasia, a rare oesophageal motility disorder

Young patients can be uniquely vulnerable to the impacts of a rare disease, diagnosed in their critical years of identity formation, social development, and planning for the future. Drawing from my journey as both a rare disease patient and a medical student, this essay explores how the rare disease achalasia has shaped my life, alongside the experiences of another young patient, Isobel. Most importantly, this essay highlights the critical role that individual healthcare professionals play in shaping young patients' experiences of their condition. Although diagnosing and managing rare diseases can be challenging due to limited research and awareness, my own experiences demonstrate that individual, intentional changes can have profound impacts. By engaging with and believing young patients, individual healthcare providers can reduce misdiagnoses, alleviate isolation and uncertainty, and ultimately, improve healthcare outcomes for young people with rare diseases.

Achalasia cardia: A case report in young female

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.

Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy

Background

Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US).

Methods

The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted.

Results

From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients.

Conclusion

The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.

Short-term outcomes after peroral endoscopic myotomy, Heller myotomy, and pneumatic dilation in patients with achalasia: a nationwide analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) are the most common modalities for management of achalasia. Our study aimed to directly compare their short-term outcomes and safety profile in a hospitalized cohort in the United States.

METHODS

The National Readmission Database (2016-2019) was queried using International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify a cohort of inpatient admissions who underwent POEM, LHM, or PD. Baseline demographic variables, resource utilization, periprocedural outcomes, and 30-day readmissions were analyzed. A univariate and multivariate logistic regression model was used to compare odds of readmission with POEM as a reference.

RESULTS

LHM was the most performed procedure (n = 9710) as compared with PD (n = 2453) and POEM (n = 1911). Patients undergoing PD were older with a higher Charlson Comorbidity Index. The 30-day readmission rate was 4.3%, 3.9%, and 12.6% for POEM, LHM, and PD, respectively. Compared with POEM, the adjusted odds of readmission for PD was 2.42 (95% confidence interval, 1.56-3.75). There was no statistically significant difference in odds of readmission for LHM (.91; 95% confidence interval, .62-1.33) compared with POEM. Within the 30-day readmitted population, 13.1% of PD and 3.4% of LHM patients required achalasia-related procedural intervention. The rate of bleeding (4.3%), blood transfusion (2.3%), and mortality were higher (1.1%) in PD as compared with POEM and LHM.

CONCLUSIONS

In the United States, the risk of readmission and resource utilization are higher in patients with achalasia undergoing PD. The outcomes are comparable between POEM and LHM, but there is a significant difference between the utilization of these myotomy procedures.

Achalasia Quality Indicator Adherence

BACKGROUND

Quality indicators (QIs) are formal ways to track health care performance and outcomes, guide quality improvement, and identify gaps in care delivery. We developed twelve quality indicators for achalasia management which cover the domains of patient education, diagnosis, and treatment of achalasia.

AIM

To determine adherence to established quality indicators for achalasia management.

METHODS

We performed a retrospective, multicenter evaluation of care patterns for adult patients greater than 18 years old with newly diagnosed achalasia from January 2018 to May 2020. A balanced random patient sample was obtained at four large academic medical centers. Independent electronic health record chart abstraction was performed using a standardized form to determine adherence to applicable QIs. Pooled and de-identified data were analyzed to identify gaps in care.

RESULTS

A total of 120 patients were included and the overall adherence to applicable quality indicators across all centers was 86%. The median follow-up for all patients from time of diagnosis to end of study was 511 days. Clinicians adhered to all applicable quality indicators in 49 patients (39%). The quality indicator domain with the poorest adherence was patient education (67%), with 50% of patients having had a documented discussion of the risks of gastroesophageal reflux disease following surgical or endoscopic myotomy.

CONCLUSIONS

Gaps in the quality of achalasia care delivery were identified, the largest of which relates to patient education about treatment risks. These findings highlight a potential area for future quality improvement studies and form the basis for developing fully specified quality measures.

Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia

BACKGROUND

Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ).

METHODS

A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed.

RESULTS

Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (β = - 10, p < .001).

CONCLUSION

Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

Achalasia

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Population trends in achalasia diagnosis and management: a changing paradigm

The Chicago Classification of esophageal motility disorders improved the differentiation of achalasia subtypes and tailored treatment. Heller myotomy (HM) and pneumatic dilation are two established treatments for achalasia. Peroral endoscopic myotomy (POEM) has become a third definitive option and is on the rise. Using the National Inpatient Sample (NIS) database, we evaluated patients hospitalized with achalasia and associated surgical and endoscopic interventions from 2013 to 2017 and compared patients undergoing HM versus POEM. The NIS database was queried to include patients with achalasia. Patients who underwent HM, POEM (only 2017 due to lack of distinct procedure code in 2013), pneumatic dilation, or esophagectomy were identified. Adverse events during the hospitalization were also queried using diagnosis codes. From 2013 to 2017, patients hospitalized with achalasia increased from 16 850 to 19 485. There were reductions in the number of esophageal dilations (10.6-5.4%, P < 0.001) and HM (18.7-13.1%, P < 0.001). In 2017, 580 POEMs were performed. Compared with patients undergoing HM in 2017, patients who had POEM had higher mean age > 64 (P = 0.004), Charlson comorbidity index (P < 0.001), disease severity (P < 0.001), and likelihood of mortality (P < 0.001). There were no differences in length of stay, mortality, or total costs between the HM and POEM groups. Patients hospitalized with achlasia increased from 2013 to 2017, possibly due to the growth and accessibility of high-resolution esophageal manometry. As expertise in POEM increases, the number of POEM performed is anticipated to rise with possible further reductions in other treatment modalities for achalasia.

Achalasia is associated with a higher incidence of depression in outpatients in Germany

Background and aim

Achalasia represents a chronic motility disorder of the esophagus featuring an impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis. By causing dysphagia, regurgitation, aspiration and chest pain, achalasia might tremendously affect life quality of patients. However, the impact of achalasia on the development of mood disorders including depression has largely remained unclear. The aim of this study was to evaluate the incidence of depression in achalasia patients.

Methods

We analyzed a large primary care cohort database in Germany capturing data from 7.49 million patients.

Results

A total of n = 1,057 patients with achalasia diagnosed between January 2005 and December 2018 were matched to a cohort of n = 3,171 patients without achalasia controlling for age, sex, physician, index year, and the Charlson comorbidity index. Interestingly, while the frequency of depression prior to the diagnosis of achalasia was comparable in both groups, new diagnoses of depression were significantly higher within one year after the diagnosis of achalasia compared to the control group, suggesting a direct and previously unrecognized association between achalasia and depression.

Conclusion

Our data suggest that the clinical management of patients with achalasia should include a careful and structured work-up for mood disorders in order to improve long-term quality of life in these patients.

Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study

BACKGROUND

Peroral endoscopic myotomy (POEM) has been shown to be effective for achalasia patients. Our study aimed to analyze the clinical outcomes of POEM for challenging patients.

METHODS

We retrospectively enrolled 278 challenging achalasia patients who underwent POEM from January 2011 to July 2019. The outcomes of POEM such as procedure time, adverse events, and risk factors of adverse events were analyzed.

RESULTS

Of the 278 patients (134 males and 144 females) with a mean age of 47.0 years, 103, 223, 93, and 98 patients had prior treatment and were Ling classification IIc/III, submucosal fibrosis (SMF) classification 2/3, and esophageal mucosa in achalasia (EMIA) classification c/d/e/f, respectively. The mean procedure time was 45.9 min (range, 15-158 min). The mean length of the tunnel and myotomy were 10.1 cm (range, 7-17 cm) and 6.6 cm (range, 5-13 cm), respectively. The major adverse event rate was 14.1%, while the minor adverse event rate was 4.7%. SMF classification 2/3 was an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. The mean follow-up time was 37.2 months (range 1-99 months). The mean Eckardt score and esophageal sphincter pressure were both significantly declined postoperatively. The clinical success rate was 95.6%.

CONCLUSION

POEM is safe and effective for challenging achalasia patients. SMF classification grade 2/3 was shown to be an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. For these patients, POEM should be performed by experienced endoscopists, some cases are better served with traditional surgery, such as minimally invasive Heller with Dor fundoplication.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation

BACKGROUND

Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients.

METHODS

Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3.

RESULTS

A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups.

CONCLUSIONS

In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia

BACKGROUND

Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia.

METHODS

Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups.

RESULTS

A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79).

CONCLUSIONS

POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

Updated Systematic Review of Achalasia, with a Focus on POEM Therapy

AIM

To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy.

METHODS

Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria.

RESULTS

Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM.

CONCLUSION

This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.

Epidemiological analysis of achalasia in Japan using a large-scale claims database

BACKGROUND

Achalasia is a well-known esophageal motility disorder, but epidemiological studies in Japan are lacking. We investigated the incidence and period prevalence of achalasia in Japan, including the rate of coexistence of esophageal carcinoma, and evaluated treatment trends.

METHODS

To estimate the nationwide number of patients with achalasia, a large-scale insurance claims database from 2005 to 2017 were used for our analyses. Patients with achalasia and coexistence of esophageal carcinoma were identified based on the diagnosis code registered. Interventional treatment was also evaluated.

RESULTS

Of the total 5,493,650 populations, 385 were diagnosed with primary achalasia. The incidence was calculated as 0.81-1.37 per 100,000 person-years (male-to-female ratio was almost 1; mean age at diagnosis was 43.3 ± 14.4 years). The period prevalence was 7.0 per 100,000 persons. There were statistically significant trends of increase in the incidence and period prevalence over age groups (all p values < 0.0001). Four men with achalasia developed esophageal carcinoma, and the incidence of esophageal carcinoma with achalasia was estimated as 0.25 per 100 person-years. With regard to intervention, esophageal dilation was performed as a first treatment in 64.7% of patients, with repeat intervention required in 56.9% of these. The proportion of patients treated using peroral endoscopic myotomy (POEM) increased annually to 41.1% in 2017.

CONCLUSIONS

In Japan, the incidence and period prevalence of achalasia is comparable to that in other countries. The absolute risk of esophageal carcinoma is rather low. Esophageal dilation has been the mainstay of achalasia treatment, and the role of POEM has increased annually.

Gender, medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

Background

High-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.

Methods

We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16-051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.

Results

In total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0-14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1-7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2-7.4; P = 0.015) were three times more likely to have hypomotility disorders.

Conclusion

From this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

The Effect of Race in Patients with Achalasia Diagnosed With High-Resolution Esophageal Manometry

BACKGROUND

The advent of the Chicago Classification for esophageal motility disorders allowed for clinically reproducible subgrouping of patients with achalasia based on manometric phenotype. However, there are limited data with regards to racial variation using high-resolution esophageal manometry (HREM). The aim of our study was to evaluate the racial differences in patients with achalasia diagnosed with HREM using the Chicago Classification. We evaluated the clinical presentation, treatment decisions and outcomes between blacks and non-blacks with achalasia to identify potential racial disparities.

MATERIALS AND METHODS

We performed a retrospective review of consecutive patients referred for HREM at a single tertiary referral center from June 2008 through October 2012. All patients diagnosed with achalasia on HREM according to the Chicago Classification were included. Demographic, clinical and manometric data were abstracted. All studies interpreted before the Chicago Classification was in widespread use were reanalyzed. Race was defined as black or non-black. Patients who had missing data were excluded. Proportions were compared using chi-squared analysis and means were compared using the Student's t-test.

RESULTS

A total of 1,268 patients underwent HREM during the study period, and 105 (8.3%) were manometrically diagnosed with achalasia (53% female, mean age: 53.8 ± 17.0 years) and also met the aforementioned inclusion and exclusion criteria. A higher percentage of women presented with achalasia in blacks as compared to whites or other races (P < 0.001). Non-blacks were more likely to present with reflux than blacks (P = 0.01), while blacks were more likely to be treated on the inpatient service than non-blacks (P < 0.001). There were no other significant differences noted in clinical presentation, treatment decisions and treatment outcomes among blacks and non-blacks.

CONCLUSIONS

Our study highlights possible racial differences between blacks and non-blacks, including a higher proportion of black women diagnosed with achalasia and most blacks presenting with dysphagia. There is possibly a meaningful interaction of race and sex in the development of achalasia that might represent genetic differences in its pathophysiology. Further prospective studies are required to identify such differences.

New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis

BACKGROUND/AIM

In this study, we aim to investigate the predicting ability of one new endoscopic classification of esophageal mucosa in achalasia (EMIA) for submucosal fibrosis (SMF) affecting the success of peroral endoscopic myotomy (POEM).

PATIENTS AND METHODS

The endoscopic and clinical data of achalasia patients undergoing POEM from 2012 to 2016 were investigated retrospectively. According to the endoscopic images or videos, EMIA and SMF grades were recorded. The relation between EMIA and SMF gradings was assessed by Spearman's rank correlation, and the predictive factors of SMF were identified by logistic regression analysis.

RESULTS

A total of 568 achalasia patients who underwent POEM were enrolled. For EMIA classification, there were 40 (7.0%), 373 (65.7%), 139 (24.5%), 14 (2.5%), 1 (0.2%), and 1 (0.2%) case (s) for grades a, b, c, d, e1, and f4, respectively. POEM procedures were aborted in 16 patients, and 93.8% (15/16) were due to severe SMF. Because grades e and f were rare and the related SMF was obvious, these two grading cases were excluded from the following analysis. Correlation between EMIA and SMF gradings was significant (Spearman r = 0.62, P < 0.01). Multivariate logistic analysis, including age, sex, disease duration, Ling classification, previous treatment, and EMIA classification, demonstrated that the EMIA classification (grades c to d) was an independent predictor for advanced SMF (odds ratio = 26.547, 95% confidence interval: 15.809-44.578, P < 0.01).

CONCLUSIONS

The new endoscopic EMIA classification is an independent predictor of advanced SMF during POEM. The classification may be used for assessment of the difficulty and success of POEM.