Assessing Esophageal Function in Achalasia: The Old and the New

Abstract

Achalasia is currently diagnosed according to the Chicago Classifi cation v3.0 using highresolution manometry and treatment focuses on disruption of the esophagogastric junction. A paper in this issue examines the utility of a timed barium esophagram with a 13 mm tablet challenge in differentiating achalasia from other diagnoses, fi nding 100% sensitivity. However, a large proportion of patients with non-achalasia dysphagia are also identifi ed. Another paper in this issue proposes utilizing intraprocedure functional luminal imaging probe measurement during pneumatic dilation as a guide for upsizing dilations. This appears promising, but prospective validation is necessary before this becomes standard of care. Am J Gastroenterol 2018; 113:213-215; doi: 10.1038/ajg.2017 High-resolution manometry (HRM), along with the analysis algorithms initially put forth in the Chicago Classifi cation (CC), and most recently updated in 2015 have led to a major reclassifi cation of esophageal motility disorders ( 1 ). Nowhere is this evolution more evident than in our concept of achalasia, now diff erentiated into three subtypes and proving to be substantially more prevalent than previously recognized ( 2,3 ). In fact, many disorders previously rendered to alternative diagnoses, or deemed to be "non-specifi c, " are also now recognized to be either achalasia subtypes or cases of incompletely expressed achalasia ( 4 ). In parallel with the global adoption of the CC, the functional luminal imaging probe (FLIP) has emerged as a novel technology capable of quantifying the distensibility of the esophagogastric junction (EGJ), and reduced EGJ distensibility has proven to be a key abnormality in achalasia. In fact, the detection of reduced EGJ distensibility can be complimentary to HRM in achalasia cases with equivocal, or even negative, HRM fi ndings ( 5 ). Furthermore, FLIP measurements can be made in real time with sedated patients, thereby off ering the potential to tailor treatment as the treatment is in progress. Together, these developments have reinvigorated our thinking about the management of esophageal motor disorders in general and achalasia in particular. Contained in this issue of the Journal are two papers pertinent to achalasia management: one exploring how an old methodology, the timed barium esophagram (TBE), fi ts into the new CC diagnostic paradigms, and the second on how FLIP might facilitate a more effi cient protocol for pneumatic dilation (PD) in achalasia therapeutics.In the fi rst paper, Blonski et al. ( 6 ) report on a retrospective analysis of 309 patients comparing TBE (including a 13 mm barium tablet challenge) with HRM in the detection and diff erentiation of achalasia, EGJ outfl ow obstruction (EGJOO), and non-achalasia dysphagia as defi ned by CC v3.0. Applying post hoc determined cutoff s for barium retention height at 1 and 5 min, they report a sensitivity and specifi city for TBE of 85% and 86%, respectively, for distinguishing achalasia from EGJOO and nonachalasia dysphagia using a retaine...

Achalasia of the Esophagus at Donka National Hospital: A Case Report

“…Achalasia occurs due to the absence of peristalsis and is a disorder of the Lower Esophageal Sphincter (LES) that affects both sexes and all ethnicities [3,4]. Our case was a young male subject.…”

Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia

“…Achalasia happens due to the absence of peristalsis and is a lower esophageal sphincter (LES) disorder that equally affects both sexes and all ethnicities [1, 2]. It is one of the rare primary motility dysfunctions of the esophagus that has no curative treatment.…”