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.

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Available from: Peter J Kahrilas
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    • "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. "
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    Full-text · Article · Jan 2015 · European Journal of Internal Medicine
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    • "Esophageal manometry has the highest sensitivity for the diagnosis of achalasia , although variations occur in manometric findings, especially in the early course of the disease [4]. Thus additional features and methodology by high-resolution manometry have been used to reinforce the diagnostic accuracy [5] [22]. "
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    • "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. "
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