Correlation of esophageal clearance and dysphagia symptom assessment after treatment for achalasia

Abstract

Background: Early relapse after treatment of achalasia occurs in 10-32 % of patients. The best method to follow up these patients is not known. Symptoms often do not correlate with esophageal clearance: some patients are oligosymptomatic despite persistent esophageal stasis/dilatation. Aim: The aim was to compare two methods of measurement of esophageal clearance (impedance manometry with barium swallow) in achalasia patients following treatment. Symptom assessment (Eckardt score/detailed dysphagia questions) was correlated with objective measurements of esophageal stasis (barium swallow and impedance manometry) in achalasia patients following treatment. Methods: Post-treatment patients were followed up after median 38.4 months (median range 1-144 months). Symptoms were quantified using the Eckardt score and detailed dysphagia questions. Timed barium swallow quantified distal esophageal retention 0.5, 1, 3, and 5 minutes after oral contrast and impedance manometry assessed total and segmental esophageal clearance during water/viscous swallows and free drinking (200 mL). Results: Thirty-two patients (7 women, age 48.3; range 20-74) completed all investigations. Bolus retention in the distal esophagus assessed by impedance correlated well with barium swallow. There were no differences in impedance and timed barium swallow parameters between patients with Eckardt score 0-2 points or !3 points. Nine (28%) patients had an Eckardt score !3 points and 21 (66%) had !1 point in the detailed dysphagia questions. Patients without any dysphagia history had lower barium column height and width at 3 and 5 minutes compared to those with !1 positive answer in the detailed dysphagia questions. Correlation between the Eckardt score and detailed dysphagia questions was moderately good (r ¼ 0.546; p ¼ 0.001). Conclusion: A detailed history of esophageal dysphagia rather than the Eckardt score is more sensitive to detect oligosymptomatic patients with disturbed esophageal clearance. Impedance manometry correlates well with the timed-barium swallow examination and represents an alternative objective assessment as it avoids radiation exposure.

Esophageal stasis in achalasia patients without symptoms after treatment does not predict symptom recurrence

“…There are conflicting results regarding this finding in previous studies. Several studies have shown that the correlation between symptoms and esophageal emptying is relatively poor . This is in line with our results, as patients with and without stasis had similar Eckardt scores, and a very poor correlation between Eckardt score and barium column height.…”

“…There are also some observational studies, however, that did find a significant association between symptom improvement and barium column height after treatment . An observational study found that a detailed history is more sensitive than the Eckardt score to detect deterioration in esophageal emptying . A few studies have shown that a high IRP on manometry after treatment is a good predictor of treatment failure, and that improvement of IRP was associated with symptom relief and improved emptying on TBE .…”

“…The treatment goal is to relieve symptoms and improve esophageal emptying . Symptoms, however, show a poor correlation with esophageal emptying, creating a subset of patients with good symptom resolution, despite poor esophageal emptying . In general, treatment is considered to have been successful when the patient has become asymptomatic, regardless of the persisting stasis of barium on TBE .…”

Achalasia: It Is Not All Black and White

“…The Eckardt score is the most widely used and reported tool to grade symptoms in achalasia [54]. While undoubtedly serving as a simple, quick, and easy measure of symptom burden in patients with achalasia, this metric offers simplicity at the expense of a limited differentiation of each symptom, which may further compound inaccuracy in assessment of disease severity using symptoms alone [55,56]. For example, regurgitation and chest pain can occur as a consequence of reflux following well-treated achalasia but may lead to a persistently high Eckardt score [57].…”

How to Optimally Apply Impedance in the Evaluation of Esophageal Dysmotility

“…The IBH correlated well with the height of the barium column on timed upright barium studies at similar time intervals in a series of achalasia patients, half of whom were treatment naive and the other half assessed after variable methods of LES disruption as therapy for their achalasia [23•]. Moreover, in another cohort of treated achalasia patients, this correlation between the IBH and barium column height remained strong at a median follow-up of over 3 years after therapy, regardless of Eckardt score [24]. Therefore, IBH can be used as a surrogate for the timed upright barium swallow in addressing adequacy of LES disruption in achalasia.…”