A Supplement to PRINTER-FRIENDLY VERSION AVAILABLE AT GASTROENDONEWS.

COM

Management of Achalasia,
Part 1: Diagnosis
OFER Z. FASS, MD
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Division of Gastroenterology and Hepatology

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Stanford University School of Medicine

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Redwood City, California

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RONNIE FASS, MD, MACG

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Esophageal and Swallowing Center

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Division of Gastroenterology and Hepatology

MetroHealth Medical System
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Case Western Reserve University

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Cleveland, Ohio
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chalasia is a rare esophageal disorder

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characterized by impaired relaxation of

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the lower esophageal sphincter (LES)

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and either absent or spastic contractions of the

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esophageal body.1 The incidence of achalasia is

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estimated to range from approximately 0.8 to 2.2

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cases per 100,000 individuals, with a prevalence

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of 7.0 to 15.3 cases per 100,000 people.2-4 The

economic burden of achalasia is significant, with
costs surpassing $400 million annually in the
United States alone.5
 The underlying cause of achalasia is believed to be
inflammatory degeneration of inhibitory neurons within the
esophageal wall, which results in abnormal peristalsis and
incomplete relaxation of the LES.6 While the exact trigger
of inflammation for primary achalasia remains unknown,
genetic studies suggest an autoimmune origin associated
with changes to HLA-DQ alleles.7,8
Secondary achalasia, on the other hand, arises from
other conditions that lead to esophageal motor abnormal-
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practitioners to maintain a high level of suspicion when
evaluating patients who exhibit symptoms that may be sug-
gestive of achalasia.
The evaluation of achalasia begins with patients present-
ing with suspicious symptoms. The most common symptom
reported by patients is dysphagia (94%) for liquids and sol-
ids.13 Other frequently reported symptoms include regurgita-
tion of undigested food and saliva (76%), particularly when
in a supine position, heartburn (52%), chest pain (41%), and

ities similar to those observed in primary achalasia. These weight loss (35%).13,14 The regurgitation may not respond to
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conditions include malignancies (“pseudoachalasia”), Chagas proton pump inhibitor treatment.11 In some cases, regurgita-
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disease, and others. 9,10 This review focuses on primary tion may lead to complications such as bronchitis or recur-
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achalasia. rent aspiration pneumonia.1,11 The differential diagnosis for

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The most prominent symptoms of achalasia include a achalasia includes gastroesophageal reflux disease (GERD),
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progressive difficulty swallowing solids and liquids that eosinophilic esophagitis (EoE), stricture, other esophageal
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often is accompanied by weight loss.11 Patients frequently motor disorders, and malignancy.
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experience regurgitation of undigested food and saliva, The Eckardt score is a standardized tool that was initially
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which can potentially lead to complications such as bron- developed to measure treatment response based on 4 prin-
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chitis or recurrent aspiration pneumonia. Diagnosing acha- cipal symptoms of achalasia: dysphagia, regurgitation, chest
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lasia can be challenging since dysphagia has a broad range pain, and weight loss (Table 1).15 It uses a 4-point scale (0-3)
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of potential causes, necessitating various examinations and for each symptom, with a maximum score of 12. A score of
supportive tests. Achalasia is not uncommonly encountered no more than 3 indicates an adequate treatment outcome.
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in gastroenterology clinics, emphasizing the importance Although the Eckardt score has not been validated as a
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of maintaining a high degree of clinical suspicion for this patient-reported outcome, it serves as a valuable tool for
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condition. assessing the severity of symptoms upon the initial diagno-

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This 2-part series focuses on the diagnosis and treat- sis of achalasia.16,17
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ment of primary achalasia, considering its distinct character-

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istics and clinical significance. Part 1 covers diagnosis, and Endoscopy

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part 2 will cover treatment. The initial diagnostic step in evaluating achalasia should
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be an upper endoscopy. The primary purpose of endos-

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Overview of Diagnosis
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copy is to identify alternative causes of esophageal symp-

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Achalasia is a condition that progresses slowly over the toms, such as mechanical obstructions or pseudoachalasia,
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course of several years, and its symptoms can be subtle. which require prompt evaluation and can mimic achalasia
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In a prospective study involving 87 individuals with acha- during esophageal manometry.18-20 However, endoscopy
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lasia, the average duration of symptoms before diagno- also can provide clues that increase suspicion for achalasia
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sis was 4.7 years.12 This highlights the need for healthcare and warrant further testing. Although the overall diagnostic
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Table 1. Eckardt Score

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Score Dysphagia Regurgitation Retrosternal pain Weight loss, kg

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0 None None None None

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1 Occasional Occasional Occasional <5

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2 Daily Daily Daily 5-10

3 Each meal Each meal Each meal >10

2 GASTROENDONEWS.COM
yield of endoscopy for achalasia is low,11 certain endoscopic
findings may raise suspicion for achalasia and prompt refer-
ral for manometric testing.
During endoscopy, the following features may suggest
achalasia (Table 2):
• dilated or tortuous esophageal lumen with a tight, but
not strictured, esophagogastric junction (EGJ);
• retained food or saliva, along with signs of stasis
esophagitis;
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a height greater than 2 cm at 5 minutes (sensitivity 80%,
specificity 86%).24
In cases where high-resolution esophageal manom-
etry (HRM) studies yield inconclusive results, a TBE is rec-
ommended to distinguish between EGJ outlet obstruction
(EGJOO) and achalasia.25,26 The TBE is relatively easy to
perform and provides reproducible results, making it a valu-
able tool in such cases.
Manometry

• rosette-like esophageal folds in the lower esopha-

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gus that appear after deep inspiration (known as the Achalasia is diagnosed based on an elevated median
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esophageal rosette sign)21; and integrated relaxation pressure (IRP) and the absence of peri-
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• the “champagne glass sign,” which is characterized stalsis during 100% of swallows.26 In other words, all swallows
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by the distal end of the contracted LES being located either occur prematurely or fail to occur. Achalasia is fur-
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proximal to the squamocolumnar junction, while the ther divided into 3 subtypes based on manometric features
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squamocolumnar junction itself appears dilated in the (Figure 1). These subtypes reflect differences in disease
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retroflexed view.22 chronicity, potential pathophysiology, response to treatment,

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Although biopsies obtained during upper endoscopy and overall prognosis.

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may be used to rule out EoE, they do not have diagnostic Type I (classic) achalasia represents an advanced
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value for achalasia. In cases of achalasia, mucosal eosino- form of the disease characterized by progressive loss
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phils may be elevated due to primary autoimmune inflam- of neuronal cell function in the distal esophagus and
mation or secondary to stasis inflammation.11 Differentiating LES that leads to progressive dilation of the esoph-
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between EoE and achalasia based solely on these findings ageal body. 27 During HRM, type I achalasia is distin-
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can be challenging. However, the presence of dysphagia to guished by absent contractility and an increase in IRP.26
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liquids and solids, along with classic manometric findings,

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can support a diagnosis of achalasia.

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Barium Esophagram
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Contrast studies using a barium esophagram play an

Table 2. Endoscopic Findings
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important role in supporting the diagnosis of achalasia and

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Suggestive of Achalasia
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providing prognostic information. This test is also valuable

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for assessing the response to therapeutic interventions.

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The classic finding on a barium esophagram in acha-

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Endoscopic finding
lasia is a dilated esophagus with a tapered EGJ that
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resembles a “bird’s beak” appearance. Other possible

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findings include aperistalsis (lack of coordinated contrac- Dilated esophageal lumen with a tight
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tions), delayed barium emptying, and in late-stage acha- (not strictured) EGJ
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lasia, a tortuous or severely dilated esophagus (sigmoid

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esophagus). Retained food or saliva with stasis esophagitis

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Timed Barium Esophagram

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Esophageal rosette sign: rosette-like folds in the

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To increase the diagnostic yield, a timed barium esoph- distal esophagus that appear after deep inspiration
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agram (TBE) with a 13-mm barium tablet can be performed.

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Including a 13-mm barium tablet improves the diagnostic

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yield for untreated achalasia from 79.5% to 100%, and is rec- Champagne glass sign: The distal end of contracted
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ommended by the American College of Gastroenterology LES is located proximal to the squamocolumnar
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guidelines.23,24 To perform a TBE, the patient typically is junction, while the squamocolumnar junction itself
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instructed to consume 200 mL of liquid barium sulfate rap- appears dilated in the retroflexed view
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idly. Upright x-ray images are then taken at different time

intervals—1 minute, 2 minutes, and 5 minutes—to measure
the height of the barium column within the esophagus.25
EGJ, esophagogastric junction; LES, lower esophageal
Abnormal findings on the barium esophagram that sup-
sphincter.
port a diagnosis of achalasia include a barium height more
than 5 cm at 1 minute (sensitivity 86%, specificity 71%) and

GASTROENTEROLOGY & ENDOSCOPY NEWS • JANUARY 2024 3


In contrast, type II achalasia is considered an earlier
form of the disease and the most common subtype iden-
tified during HRM. It is characterized by a panesophageal
pressure wave of at least 30 mm Hg.26 This pressure wave
is generated by non-lumen obliterating esophageal con-
tractions, similar to what occurs when a water balloon is
squeezed.27
Type III (spastic) achalasia is the least common subtype
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This may occur due to a tight LES, diverticulum, or tortuous
esophagus that results in an inability to pass the probe into
the stomach.
To confirm the diagnosis of achalasia in cases of incon-
clusive findings and dysphagia symptoms, the Chicago
Classification version 4.0 recommends supportive testing
with either TBE or a functional lumen imaging probe (FLIP).
In untreated patients, a barium height more than 2 cm at
5 minutes has a sensitivity of 80% and specificity of 86% for

and may involve a different pathophysiology compared differentiating achalasia from other disorders.24 In a study
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with types I and II, with less destruction of neurons from the evaluating FLIP, 13 patients with typical achalasia symptoms,
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myenteric plexus within the distal esophagus.28,29 It is char- absent peristalsis on HRM, and an IRP at the upper limit
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acterized by HRM findings that include at least 20% pre- of normal showed lower EGJ distensibility than 15 healthy
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mature and spastic swallows, defined by a distal latency of controls.30 In addition, these patients responded favorably
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less than 4.5 seconds and a distal contractile integral of at to achalasia-specific treatments, showing improvements in
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least 450 mm Hg·s·cm.26 The remaining swallows that are both reported Eckardt score and EGJ distensibility.
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not premature must either fail or fail with panesophageal HRM testing also can play a role in differentiating opioid-
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pressurization. induced esophageal motility disorders from type III achala-

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In certain cases, the diagnosis of achalasia type I or sia. Chronic opioid use has been shown to cause elevated
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II may be inconclusive. This can occur if a patient with IRP and peristaltic abnormalities resembling those seen in
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HRM patterns consistent with achalasia type I or II devel- patients with EGJOO and type III achalasia.31 Ideally, HRM
ops noticeable peristalsis when transitioning between should be performed when patients are not taking opioids,
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the supine and upright positions.26 In addition, achalasia but discontinuing opioid medications may not always be
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patients may demonstrate 100% absent contractility or pan- feasible for patients. In such cases, pharmacologic provo-
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esophageal pressurization but with borderline or normal IRP. cation with amyl nitrite and cholecystokinin has been shown
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Figure 1. Achalasia subtypes defined by high-resolution esophageal manometry.

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All achalasia subtypes must have an elevated median integrated relaxation pressure and absence of peristalsis
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during 100% of swallows. Type I achalasia is distinguished by a distal contractile integral of <100 mm Hg·s·cm and
the absence of panesophageal pressurization. Type II achalasia is characterized by a panesophageal pressure wave
≥30 mm Hg. Type III achalasia is represented by ≥20% premature and spastic swallows, defined by a distal latency
of <4.5 s and a distal contractile integral ≥450 mm Hg·s·cm.26

Figure from Ronnie Fass, MD.

4 GASTROENDONEWS.COM
to differentiate between opioid-induced esophageal motility
disorder and type III achalasia.32 Opioid-exposed patients
demonstrate an attenuated rebound contraction of the LES
during amyl nitrite recovery and esophageal contraction
during the first phase of cholecystokinin response.
The FLIP Assessment
Various studies have established the utility of FLIP in
identifying achalasia (Figure 2). In one study involving 40
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heterogeneous among patients with type II achalasia.34
Furthermore, a large retrospective study involving 240
achalasia patients demonstrated that a low EGJ distensibil-
ity index is valuable for distinguishing patients from healthy
controls. In addition, specific components of the distensibil-
ity index, such as a maximum EGJ diameter less than 16 mm,
can increase the sensitivity of FLIP in diagnosing achalasia
even when the EGJ distensibility index appears normal.35
FLIP also has the potential to identify patients with acha-

patients referred for endoscopy and HRM, all 9 patients lasia-like symptoms but an inconclusive diagnosis, who
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with achalasia showed abnormal FLIP metrics, character- may benefit from achalasia-directed treatment. Studies
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ized by reduced EGJ opening (EGJ distensibility index have shown that patients with achalasia symptoms and
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<2.8 mm2/mm Hg) and an abnormal contractile response absent peristalsis on HRM but IRP values at the upper limit
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to distension.33 Another study of 145 patients with nonob- of normal have lower a EGJ distensibility index compared
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structive dysphagia found that among the 70 patients with with healthy controls and respond favorably to achalasia
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confirmed achalasia on HRM, all exhibited abnormal FLIP treatment.30 These results have been supported by other
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measurements of reduced EGJ opening and abnormal studies. 36 Similarly, a retrospective study of 89 patients
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contractility. However, the contractility patterns were more undergoing peroral endoscopic myotomy (POEM) identified
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Figure 2. Characteristics of achalasia defined by FLIP.

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A FLIP study in a patient with achalasia. Balloon volume at 50 mL demonstrates a distensibility index of 0.52,
diameter of 4.7 mm, pressure of 33.1 mm Hg, and absent contractility.33
FLIP, functional lumen imaging probe.

Figure from Ronnie Fass, MD.

GASTROENTEROLOGY & ENDOSCOPY NEWS • JANUARY 2024 5

24 individuals with achalasia-like symptoms, failed peristal-
sis, and normal IRP values. These patients had a higher
EGJ distensibility index (mean value, 2.75 mm 2/mm Hg)
but responded well to POEM, with a reduction in Eckhardt
score.37
FLIP serves as a complementary diagnostic tool to HRM
and can be used as confirmatory testing when there is
ambiguity in diagnosing achalasia. However, FLIP has not
yet been shown to accurately differentiate between the
A
wall, contributing to its subtle and progressive nature. While
endoscopy is crucial for excluding secondary causes, HRM
stands out as the definitive diagnostic tool for primary acha-
lasia. In instances of diagnostic ambiguity, TBE and FLIP
assume pivotal roles, not only in clarifying diagnoses but
also in evaluating treatment responses.
The diagnostic process hinges on maintaining a high clin-
ical suspicion, particularly when patients present with hall-
mark symptoms such as dysphagia, regurgitation, heartburn,

subtypes of achalasia. chest pain, and weight loss. This recognition is paramount
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for timely intervention and improved patient outcomes. The

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Conclusion comprehensive understanding of achalasia’s diagnostic

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Achalasia is a complex esophageal motility disorder nuances, coupled with the strategic use of advanced tech-
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that has a significant impact on patients’ well-being and niques like HRM, TBE, and FLIP, equips clinicians to nav-
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healthcare resources. Its etiology involves the inflammatory igate the complexities of this condition and offer optimal
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degeneration of inhibitory neurons within the esophageal care to those affected.

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References
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Neurogastroenterol Motil. 2017;29(1):e12908.
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31. Babaei A, Szabo A, Shad S, et al. Chronic daily opioid exposure is

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associated with dysphagia, esophageal outflow obstruction and Ofer Fass reported no relevant financial disclosures.
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disordered peristalsis. Neurogastroenterol Motil. 2019;31(7):e13601. Ronnie Fass is an advisor for Medtronic, speaker for Laborie,
and receives research support from Diversatek. He is a member
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of the Gastroenterology & Endoscopy News editorial board.

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A Supplement to PRINTER-FRIENDLY VERSION AVAILABLE AT GASTROENDONEWS.COM A Supplement to PRINTER-FRIENDLY VERSION AVAILABLE AT GASTROENDONEWS.COM
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Challenges in the Diagnosis Health Maintenance for Patients

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Of Barrett’s Esophagus and With Inflammatory Bowel

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Related Neoplasia: Disease

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Top 10 FAQs OSCAR RAMIREZ RAMIREZ, MD

Division of Internal Medicine
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FREDDY CALDERA, DO, MS

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Division of Gastroenterology and

Hepatology
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Department of Medicine
School of Medicine and Public Health
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University of Wisconsin–Madison
ABHILASH PERISETTI, MD Madison, Wisconsin
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Department of Gastroenterology
Kansas City VA Medical Center
Kansas City, Missouri
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PRATEEK SHARMA, MD
Department of Gastroenterology
haracterized by chronic

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Kansas City VA Medical Center
Kansas City, Missouri
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inflammation of the
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Division of Gastroenterology and

Hepatology
Department of Internal Medicine gastrointestinal tract
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University of Kansas School of Medicine

Kansas City, Kansas
resulting in abdominal pain,
diarrhea, and other chronic
symptoms, inflammatory bowel
ot

Risk factors for BE include older age, male sex, white

race, long-standing gastroesophageal reflux disease, posi- disease is estimated to affect
arrett’s esophagus

B is the premalignant
tive family history, and tobacco smoking. Given the risk for
malignant transformation, early identification of BE-related
at least 3.1 million people in the
he

neoplasia is essential because these lesions can har- United States.1 Patients with
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condition for esophageal
adenocarcinoma, characterized
bor cancer, which may be curable if identified early. With
advances in endoscopic visualization and interventions, IBD are at increased risk for
detection and characterization of both BE and BERN have
vaccine-preventable diseases,
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by transformation of the normal improved significantly.

Despite these advances, there is a BERN miss rate of
er

malignancies, and bone mineral

squamous lining of the esophagus up to 25%.1 Gastroenterologists can encounter challenges
in the diagnosis of BE, evaluation of BE segments, identifi- disease, making preventive care
to columnar epithelium. cation of BERN lesions, intricacies of histologic interpreta-
is

paramount in this population.

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tion, appropriate use of scoring systems, and optimal time

frame for BE surveillance. In this article, we aim to highlight
some of the most common challenging clinical scenarios in
e

the diagnosis of BE and offer practical solutions.

is

no

G A S T R O E N T E R O L O G Y & E N D O S C O P Y N E W S • J U LY 2 0 2 3 1 GASTROENTEROLOGY & ENDOSCOPY NEWS • JUNE 2023 1

si
on

te
d.
is

A Supplement to PRINTER-FRIENDLY VERSION AVAILABLE AT GASTROENDONEWS.COM A Supplement to PRINTER-FRIENDLY VERSION AVAILABLE AT GASTROENDONEWS.COM
pr

Splenic Injury in Colonoscopy Improving the Safety of Endoscopy

oh

Prevention, Management & Malpractice Issues Procedures in Pregnant Patients

ib

WAQAR QURESHI, MD, FRCP (UK),

NIHARIKA MALLEPALLY, MD, MPH STEVEN BOLLIPO, FRACP FACG, FASGE
Gastroenterology Fellow Director of Gastroenterology and Endoscopy
ite

Professor of Medicine
Division of Gastrointestinal and Liver Disease John Hunter Hospital
Baylor College of Medicine
University of Southern California Newcastle, Australia
Houston, Texas
Los Angeles
d.

lthough about 20,000

A gastrointestinal endoscopies
(0.4% of all endoscopies) are
performed in pregnant patients in the
United States each year,1 endoscopy
in this setting often causes anxiety
and hesitation for both the physician
and patient. These reactions are
understandable given the paucity of
safety data on endoscopy for the fetus
during the procedure. Both mother and
baby are at risk during the procedure,
and it is difficult to reliably monitor fetal
well-being.

I
n the half-century since the first colonoscopy was performed in 1969, the procedure has
become a mainstay for managing colorectal cancer screening and assessing bowel
symptoms.1 In the United States alone, approximately 16 million colonoscopies are
performed annually.2

G A S T R O E N T E R O L O G Y & E N D O S C O P Y N E W S • M AY 2 0 2 3 1
GASTROENTEROLOGY & ENDOSCOPY NEWS • APRIL 2023 1