Achalasia: A New Clinically Relevant Classification by High-Resolution Manometry

Northwestern University, The Feinberg School of Medicine, Department of Medicine, Chicago, Illinois, USA.
Gastroenterology (Impact Factor: 16.72). 08/2008; 135(5):1526-33. DOI: 10.1053/j.gastro.2008.07.022
Source: PubMed


Although the diagnosis of achalasia hinges on demonstrating impaired esophagogastric junction (EGJ) relaxation and aperistalsis, 3 distinct patterns of aperistalsis are discernable with high-resolution manometry (HRM). This study aimed to compare the clinical characteristics and treatment response of these 3 subtypes.
One thousand clinical HRM studies were reviewed, and 213 patients with impaired EGJ relaxation were identified. These were categorized into 4 groups: achalasia with minimal esophageal pressurization (type I, classic), achalasia with esophageal compression (type II), achalasia with spasm (type III), and functional obstruction with some preserved peristalsis. Clinical and manometric variables including treatment response were compared among the 3 achalasia subtypes. Logistic regression analysis was performed using treatment success as the dichotomous dependent variable controlling for independent manometric and clinical variables.
Ninety-nine patients were newly diagnosed with achalasia (21 type I, 49 type II, 29 type III), and 83 of these had sufficient follow-up to analyze treatment response. Type II patients were significantly more likely to respond to any therapy (BoTox [71%], pneumatic dilation [91%], or Heller myotomy [100%]) than type I (56% overall) or type III (29% overall) patients. Logistic regression analysis found type II to be a predictor of positive treatment response, whereas type III and pretreatment esophageal dilatation were predictive of negative treatment response.
Achalasia can be categorized into 3 subtypes that are distinct in terms of their responsiveness to medical or surgical therapies. Utilizing these subclassifications would likely strengthen future prospective studies of treatment efficacy in achalasia.

Download full-text


Available from: Peter J Kahrilas,
  • Source
    • "c o m / l o c a t e / e j i m Please cite this article as: Marano L, Di Martino N, " Cor bovinum " : An ambiguous chest radiography, Eur J Intern Med (2014), 10.1016/j.ejim.2014.12.005 introduction of high-resolution manometry [3] have permitted to categorized patients into 3 subtypes that can predict patient response to endoscopic or surgical treatment: type II patients were significantly more likely to respond to any therapy than type I or type III patients [1]. The goal of the current therapeutic options is the longterm relief of symptoms , preventing the recurrences and improving the quality of life. "
    [Show abstract] [Hide abstract]
    ABSTRACT: A 65-year-old woman, affected by Type II diabetes mellitus with no history of cardiac illness, referred to our hospital with a suspected diagnosis of “angina pectoris” for a cardiovascular evaluation. The patient's physical examination was unremarkable and cardiac laboratory tests, electrocardiogramand transthoracic echocardiogram were also normal. A standard chest X-ray revealed an ambiguous cor bovinum-like mediastinal image constituted of dilated thoracic esophagus profile. At upper gastrointestinal endoscopy any malignancies were ruled out and in-esophagus food stagnation with difficult crossing through the esophagogastric junction was assessed. A diagnosis of esophageal achalasia was suggested and then confirmed by high resolution manometry as the type 2 esophageal achalasia according to Chicago classification . The patient underwent a laparoscopic Heller's myotomy with Dor fundoplication, and at follow-up 12 months later she remained completely asymptomatic.
    European Journal of Internal Medicine 01/2015; 26(6). DOI:10.1016/j.ejim.2014.12.005 · 2.89 Impact Factor
  • Source
    • "In patients with achalasia having panesophageal pressurization in response to swallowing (n = 9), maximal pressure observed in the distal segment was also evaluated, according to Pandolfino et al20 as a further index of contractility after swallows. Briefly, maximal pressure was calculated by scrolling up the isobaric contour tool to the pressure value at which no isobaric area was identified within the distal esophageal segment. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Swallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry. Fifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order. In healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively). Our data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.
    Journal of neurogastroenterology and motility 01/2014; 20(1):79-86. DOI:10.5056/jnm.2014.20.1.79 · 2.30 Impact Factor
  • Source
    • "Although achalasia can be suspected using clinical, radiographic , and endoscopic information, definite diagnosis can only be made using esophageal manometry [2], which shows the absence of esophageal motility and in most cases inappropriate lower esophageal sphincter (LES) relaxation. High-resolution manometry can be used to further study esophageal motility in patients with achalasia by categorizing patients into 3 subtypes that can predict patient response to endoscopic or surgical treatment [3]. Treatment for patients with achalasia focuses on symptoms improvement. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Achalasia is an esophagealmotility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Hellermyotomy is considered bymany experts as the best treatment modality formost patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy.We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.
    Gastroenterology Research and Practice 10/2013; 2013(2). DOI:10.1155/2013/708327 · 1.75 Impact Factor
Show more