From the AGA Journals

Manometry, esophagram combo detects achalasia posttreatment problems

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Symptoms Are Unreliable Marker

Most patients with achalasia do well in the postoperative period after either pneumatic dilation (PD) or laparoscopic surgical myotomy, with an initial success rate as high as 90% after 2 years. However, predicting failure based on symptom recurrence is problematic, as symptoms are often underreported or absent due to esophageal dilation or impaired esophageal sensation. Thus, a strategy of avoiding esophageal decompensation due to delayed diagnosis cannot solely rely on patient report of symptom recurrence. Objective testing by barium esophagram or esophageal manometry may be needed.

Dr. Michael Vaezi

This study adds new knowledge regarding the benefit of high-resolution manometry (HRM) in the management of posttreatment achalasia. The novelty of the study is in its use of timed barium esophagram (TBE), HRM, and symptoms in a group of patients with achalasia pre- and posttherapy. TBE was previously advocated as the objective test of choice; however, this study suggests that TBE and HRM may be complementary in this regard.

What is clear from this report as well as others regarding objective testing in achalasia is that patients’ symptoms alone are a poor marker of esophageal emptying. Posttherapy testing with HRM and/or TBE with special emphasis on bolus emptying should be employed in order to avoid long-term complications with achalasia. The choice between the tests may depend on the expertise and availability of each of the proposed test modalities.

Dr. Vaezi is clinical director of the division of gastroenterology, hepatology, and nutrition, and director of the Center for Swallowing and Esophageal Disorders and Clinical Research at Vanderbilt University Medical Center, Nashville, Tenn. He said he had no conflicts of interest to disclose.



High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

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