Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Gyeonggi-do, Korea.
Abstract
BACKGROUND/AIMS Achalasia is classified into 3 types according to the Chicago classification. The aim of this study was to investigate characteristics and treatment outcomes of 3 achalasia subtypes in Korean patients.
METHODS Fifty-five patients diagnosed with achalasia based on conventional or high-resolution esophageal manometry were consecutively enrolled. Their clinical characteristics, manometric, endoscopic and esophagographic findings and treatment responses were analyzed among the 3 subtypes of achalasia.
RESULTS Of 55 patients, 21 (38.2%) patients had type I, 28 (50.9%) patients had type II and 6 (10.9%) patients had type III. The median follow-up period was 22.4 (interquartile range, 3.6-67.4) months. Type III patients were older than type I and II patients (70.0 vs. 46.2 and 47.6 years, P = 0.023). The width of the esophagus in type I patients was wider with more frequent bird's beak appearance on esophagogram than the other 2 types (P = 0.010 and 0.006, respectively). Of the 50 patients who received the evaluation for treatment response at 3 months, 7 patients (36.8% vs. 26.9%) were treated with pneumatic dilatation and 4 patients (21.1% vs. 15.4%) with laparoscopic Heller's myotomy in type I and II groups, respectively. The treatment responses of pneumatic dilatation and Heller's myotomy in type I group were 71.4 and 50.0% and in type II were 85.7 and 75.0%, respectively, and all 5 patients in type III group showed good response to medical therapy.
CONCLUSIONS Clinical characteristics of 3 achalasia subtypes in Korean patients are consistent with other studies. Treatment outcomes are variable among 3 subtypes.
Figure 1Three subtypes of achalasia based on the high-resolution manometry. A similar classification can be made when conventional manometry is used. Type I, achalasia with minimal esophageal pressurization (A); type II, achalasia with esophageal compression (B); type III, achalasia with spasm (C).Figure 2Representative esophagogram and upper gastrointestinal endoscopy findings of 3 achalasia subtypes (Type I - A, D; Type II - B, E; Type III - C, F). Marked dilatation of the esophagus and bird's beak appearance are noted on the esophagogram (A). Moderately dilated esophagus is noted and the proximal esophagus is filled with air which is evident by the associated esophagogram (B). The associated esophagogram for type III achalasia is often interpreted as esophageal spasm as this has an extreme corkscrew with distal contraction (C). Food stasis and flaccid esophagus are noted on the upper gastrointestinal endoscopy (D). Narrow gastroesophageal junction is noted on the upper gastrointestinal endoscopy and the scope can pass through with resistance (E). Upper gastrointestinal endoscopy findings are nearly normal in type III achalasia (F).Figure 3Short-term (3 months) treatment responses of the 50 achalasia patients. Type II achalasia shows good treatment outcomes in pneumatic dilatation (PD; 6/7, 85.7%) and laparoscopic Heller's myotomy (LHM; 3/4, 75.0%) in comparison with type I achalasia (5/7, 71.4% in PD and 2/4, 50.0% in LHM). All type III achalasia patients responded to calcium channel blocker (CCB) (A). Long-term (≥ 5 years) treatment responses and clinical follow-up of the 13 achalasia patients. Of the 13 patients, 2 patients who showed good response on PD or LHM relapsed after 5 years and the symptoms of 3 achalasia patients who showed poor response to initial PD or LHM persisted which needed further treatment. *Two achalasia patients who were treated with CCB were followed up with high-resolution manometry (B). Others include proton pump inhibitor, motility drug or antacid. Stable means Eckardt symptom score 3 or less. Relapse means Eckardt symptom more than 3. Good, good response; Poor, poor response.Figure 4Long-term follow-up monometric finding of anachalasia patient. One 53 year-old woman who complained of dysphagia was diagnosed as having achalasia by conventional manometry (CM), 8.7 years ago. On CM, peak amplitudes 18, 13, 8 and 3 cm proximal to LES were 26, 25, 32 and 43 mmHg, respectively and these findings were compatible with type II achalasia (A). She was recently followed up with high-resolution manometry (HRM). On HRM, the color plot showed a minimal esophageal body pressure below 20 mmHg, and HRM findings were compatible with type I achalasia (B). These follow-up results reveal the evidence of esophageal decompensation in this patient. The initial esophagogram showed a standing column of barium with mild passage disturbance inthe distal esophagus; the maximal width of the esophagus was 32.2 mm. A follow-up esophagogram showed more dilated esophagus and a maximal width of 57.3 mm. Upper gastrointestinal endoscopy findings were normal in the initial and follow-up studies.
그림 출처: PubMed Central 공개 논문 (PMC3816183)
Conflict of interest statement
Conflicts of interest: None.
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Journal of neurogastroenterology and motility · ISSN 2093-0879
