Limits...
Achalasia Cardia Subtyping by High-Resolution Manometry Predicts the Therapeutic Outcome of Pneumatic Balloon Dilatation

Pratap N, Kalapala R, Darisetty S, Joshi N, Ramchandani M, Banerjee R, Lakhtakia S, Gupta R, Tandan M, Rao GV, Reddy DN - J Neurogastroenterol Motil (2011)

Bottom Line: The clinical and manometric variables and treatment outcomes were compared.Fifty-one patients with a minimum follow-up period of 6 months were included.Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II.

Affiliation: Asian Institute of Gastroenterology, Hyderabad, India.

ABSTRACT

Background/aims: High-resolution manometry (HRM) with pressure topography is used to subtype achalasia cardia, which has therapeutic implications. The aim of this study was to compare the clinical characteristics, manometric variables and treatment outcomes among the achalasia subtypes based on the HRM findings.

Methods: The patients who underwent HRM at the Asian Institute of Gastroenterology, Hyderabad between January 2008 and January 2009 were enrolled. The patients with achalasia were categorized into 3 subtypes: type I - achalasia with minimum esophageal pressurization, type II - achalasia with esophageal compression and type III - achalasia with spasm. The clinical and manometric variables and treatment outcomes were compared.

Results: Eighty-nine out of the 900 patients who underwent HRM were diagnosed as achalasia cardia. Fifty-one patients with a minimum follow-up period of 6 months were included. Types I and II achalasia were diagnosed in 24 patients each and 3 patients were diagnosed as type III achalasia. Dysphagia and regurgitation were the main presenting symptoms in patients with types I and II achalasia. Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II. Most patients underwent pneumatic dilatation (type I, 22/24; type II, 20/24; type III, 3/3). Patients with type II had the best response to pneumatic dilatation (18/20, 90.0%) compared to types I (14/22, 63.3%) and III (1/3, 33.3%).

Conclusions: The type II achalasia cardia showed the best response to pneumatic dilatation.

Achalasia subtypes. (A) Type I (classic achalasia), there is no significant pressurization within the body of the esophagus. (B) Type II (achalasia with compression), there is rapid pan-esophageal pressurization. (c) Type III (spastic achalasia), this swallow shows spastic contraction.
© Copyright Policy

Figure 1: Achalasia subtypes. (A) Type I (classic achalasia), there is no significant pressurization within the body of the esophagus. (B) Type II (achalasia with compression), there is rapid pan-esophageal pressurization. (c) Type III (spastic achalasia), this swallow shows spastic contraction.

Mentions: The patients with impaired LES relaxation were divided into 3 subtypes based on the dominant feature of the distal esophageal pressure after swallowing.10,11 Clinical, manometric variables and treatment outcomes were compared among the 3 subtypes. For type I achalasia (classic achalasia), the distal esophageal pressure was less than 30 mmHg in more than 8 out of the 10 wet swallows (Figure A). For type II achalasia (achalasia with esophageal compression), at least 2 out of the 10 wet swallows were associated with a pan esophageal pressurization greater than 30 mmHg (Figure B). For type III achalasia (spastic achalasia), there were 2 or more spastic contractions (contractile front velocity [CFV] > 8 cm/s)11 with or without periods of compartmentalized pressurization (Figure C). The CFV was calculated from the slope of the line connecting the 30 mmHg isobaric contour at the proximal margin of S2 and the distal margin of the S3. Endoscopic pneumatic dilatation was performed using a Rigiflex balloon with a 35 mm diameter (Microvasive). The balloon was placed over an endoscopically introduced guide wire and positioned across the LES. After confirmation of the position by fluoroscopy, the balloon was left inflated for 1 minute. The need for further dilatation was determined by the persistence of symptoms 4 weeks after treatment. The patients were followed for 6 months after endoscopic pneumatic dilatation. A successful treatment response was defined as symptomatic relief requiring no further intervention up to 6 months after a single intervention.13

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3042218&rFormat=json&query=null&req=5
Achalasia Cardia Subtyping by High-Resolution Manometry Predicts the Therapeutic Outcome of Pneumatic Balloon Dilatation

Pratap N, Kalapala R, Darisetty S, Joshi N, Ramchandani M, Banerjee R, Lakhtakia S, Gupta R, Tandan M, Rao GV, Reddy DN - J Neurogastroenterol Motil (2011)

Achalasia subtypes. (A) Type I (classic achalasia), there is no significant pressurization within the body of the esophagus. (B) Type II (achalasia with compression), there is rapid pan-esophageal pressurization. (c) Type III (spastic achalasia), this swallow shows spastic contraction.
© Copyright Policy
Figure 1: Achalasia subtypes. (A) Type I (classic achalasia), there is no significant pressurization within the body of the esophagus. (B) Type II (achalasia with compression), there is rapid pan-esophageal pressurization. (c) Type III (spastic achalasia), this swallow shows spastic contraction.
Mentions: The patients with impaired LES relaxation were divided into 3 subtypes based on the dominant feature of the distal esophageal pressure after swallowing.10,11 Clinical, manometric variables and treatment outcomes were compared among the 3 subtypes. For type I achalasia (classic achalasia), the distal esophageal pressure was less than 30 mmHg in more than 8 out of the 10 wet swallows (Figure A). For type II achalasia (achalasia with esophageal compression), at least 2 out of the 10 wet swallows were associated with a pan esophageal pressurization greater than 30 mmHg (Figure B). For type III achalasia (spastic achalasia), there were 2 or more spastic contractions (contractile front velocity [CFV] > 8 cm/s)11 with or without periods of compartmentalized pressurization (Figure C). The CFV was calculated from the slope of the line connecting the 30 mmHg isobaric contour at the proximal margin of S2 and the distal margin of the S3. Endoscopic pneumatic dilatation was performed using a Rigiflex balloon with a 35 mm diameter (Microvasive). The balloon was placed over an endoscopically introduced guide wire and positioned across the LES. After confirmation of the position by fluoroscopy, the balloon was left inflated for 1 minute. The need for further dilatation was determined by the persistence of symptoms 4 weeks after treatment. The patients were followed for 6 months after endoscopic pneumatic dilatation. A successful treatment response was defined as symptomatic relief requiring no further intervention up to 6 months after a single intervention.13

Bottom Line: The clinical and manometric variables and treatment outcomes were compared.Fifty-one patients with a minimum follow-up period of 6 months were included.Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II.

Affiliation: Asian Institute of Gastroenterology, Hyderabad, India.

ABSTRACT

Background:

Background/aims: High-resolution manometry (HRM) with pressure topography is used to subtype achalasia cardia, which has therapeutic implications. The aim of this study was to compare the clinical characteristics, manometric variables and treatment outcomes among the achalasia subtypes based on the HRM findings.

Methods: The patients who underwent HRM at the Asian Institute of Gastroenterology, Hyderabad between January 2008 and January 2009 were enrolled. The patients with achalasia were categorized into 3 subtypes: type I - achalasia with minimum esophageal pressurization, type II - achalasia with esophageal compression and type III - achalasia with spasm. The clinical and manometric variables and treatment outcomes were compared.

Results: Eighty-nine out of the 900 patients who underwent HRM were diagnosed as achalasia cardia. Fifty-one patients with a minimum follow-up period of 6 months were included. Types I and II achalasia were diagnosed in 24 patients each and 3 patients were diagnosed as type III achalasia. Dysphagia and regurgitation were the main presenting symptoms in patients with types I and II achalasia. Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II. Most patients underwent pneumatic dilatation (type I, 22/24; type II, 20/24; type III, 3/3). Patients with type II had the best response to pneumatic dilatation (18/20, 90.0%) compared to types I (14/22, 63.3%) and III (1/3, 33.3%).

Conclusions: The type II achalasia cardia showed the best response to pneumatic dilatation.

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3042218&rFormat=json&query=null&req=5