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Achalasia and Ineffective Esophageal Motility

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Principles of Deglutition

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Abstract

Achalasia and ineffective esophageal motility (IEM) represent the extreme ends of the spectrum of esophageal motility disorders. Achalasia is characterized by aperistalsis in the body of the esophagus and failure of LES relaxation. Patients present with dysphagia for solids and liquids, bland regurgitation, chest pain, and weight loss. The diagnosis is suggested by the barium esophagram and confirmed by manometry. The goal of therapy is to (1) relieve symptoms, (2) improve esophageal emptying by disrupting the poorly relaxing LES, and (3) prevent the development of megaesophagus. Surgical myotomy and pneumatic dilation are the most effective treatments for disrupting the LES gradient. Botulinum toxin and calcium channel blockers may be useful therapies in older patients or those with severe co-morbid illnesses. Ineffective esophageal peristalsis is characterized by the presence of distal esophageal contractions of very low amplitude (<30 mmHg) and/or non-transmitted contractions. It is the most common motility disorder in GERD patients, probably due to impaired cholinergic stimulation along the esophageal body. The diagnosis is best made with esophageal manometry combined with impedance testing to confirm poor bolus transit. Once established, IEM is not improved by acid-suppressive medications, most prokinetic drugs, or anti-reflux surgery.

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References

  1. Willis T. Pharmaceutic rationalis: sive diatriba de medicamentorum; operatimibus in humano corpore. London: Hagae-Comitis; 1674.

    Google Scholar 

  2. Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin North Am. 2001;11:235–47.

    CAS  Google Scholar 

  3. Eckhardt VF, Hoischen T, Bernhard G. Life expectancy, complications and causes of death in patients with achalasia: results of a 33-year follow-up investigation. Eur J Gastroenterol Hepatol. 2008;20:956–60.

    Article  Google Scholar 

  4. Goldblum JR, Whyte RI, Orringer MB, et al. Achalasia: a morphologic study of 42 resected specimens. Am J Surg Pathol. 1994;18:327–37.

    Article  PubMed  CAS  Google Scholar 

  5. Goldblum JR, Rice TW, Richter JE. Histopathologic features in esophagomyotomy specimens from patients with achalasia. Gastroenterology. 1996;111:648–54.

    Article  PubMed  CAS  Google Scholar 

  6. Holloway RH, Dodds WJ, Helm JF, et al. Integrity of cholinergic innervation to the lower esophageal sphincter in achalasia. Gastroenterology. 1986;90:924–9.

    PubMed  CAS  Google Scholar 

  7. Park W, Vaezi MF. Etiology and pathogenesis of achalasia: the current understanding. Am J Gastroenterol. 2005;100:1401–14.

    Google Scholar 

  8. Ruiz-De-Leon A, Mendoza J, De-La-Concha EG, et al. Myenteric antiplexus antibodies and class II HLA in achalasia. Dig Dis Sci. 2002;47:15–9.

    Article  PubMed  Google Scholar 

  9. Moses PL, Ellis LM, Anees MR, et al. Antineuronal antibodies in idiopathic achalasia and gastroesophageal reflux disease. Gut. 2003;52:629–36.

    Article  PubMed  CAS  Google Scholar 

  10. Niwamoto H, Okamoto E, Fujmoto J, et al. Are human herpes viruses or measles virus associated with esophageal achalasia? Dig Dis Sci. 1995;40:859–64.

    Article  PubMed  CAS  Google Scholar 

  11. Birgissen S, Galinski MS, Goldblum JR, et al. Achalasia is not associated with measles as known herpes or human papilloma viruses. Dig Dis Sci. 1997;42:300–6.

    Article  Google Scholar 

  12. Facco M, Brun P, Zaninotto G, et al. T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens. Am J Gastroenterol. 2008;103:1598–609.

    Article  PubMed  Google Scholar 

  13. Eckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: patient characteristics and clinical course. Gastroenterology. 1999;116:1300–4.

    Article  PubMed  CAS  Google Scholar 

  14. DeOliveira JMA, Birgisson S, Doinoff C, et al. Timed-barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. Am J Roentgenol. 1997;169:473–9.

    CAS  Google Scholar 

  15. Ghosh SK, Pandolfino JE, Rice J, et al. Impaired deglutitive ECJ relaxation in clinical manometry: a quantitative analysis of 400 patients and 75 controls. Am J Physiol Gastrointest Liver Physiol. 2007;293(4):G878–85.

    Article  PubMed  CAS  Google Scholar 

  16. Pandolfino JE, Kwiatek MA, Nealis T, et al. Achalasia: a new clinically relevant classification by high resolution manometry. Gastroenterology. 2008;135:1526–33.

    Article  PubMed  Google Scholar 

  17. Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. High resolution manometry in clinical practice: utilizing pressure topography to classify oeosophageal motility abnormalities. Neurogastroenterol Motil. 2009;21:796–806.

    Article  PubMed  CAS  Google Scholar 

  18. Herbella FAM, Aquino JLB, Stefani-Nokana S, et al. Treatment of achalasia: lessons learned from Chagas’ disease. Dis Esophagus. 2008;21:461–7.

    Article  PubMed  CAS  Google Scholar 

  19. Gockel I, Eckhard VF, Schmitt T, Junginger T. Pseudoachalasia: a case series and analysis of the literature. Scand J Gastroenterol. 2005;40:378–85.

    Article  PubMed  Google Scholar 

  20. Sandler RS, Bozymski EM, Orlando RC. Failure of clinical criteria to distinguish between primary achalasia and achalasia secondary to tumor. Dig Dis Sci. 1982;27:209–13.

    Article  PubMed  CAS  Google Scholar 

  21. Eckhardt VF, Kohne A, Junginger T, et al. Risk factors for diagnostic delay in achalasia. Dig Dis Sci. 1997;42:580–5.

    Article  Google Scholar 

  22. Vela MF, Richter JE, Wachsberger D, et al. Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilation, Heller myotomy and botulinum toxin injection. Am J Gastroenterol. 2004;2:389–94.

    Google Scholar 

  23. Vaezi MF, Baker MF, Achkar E, Richter JE. Timed barium esophagram: better predictor of long-term success after pneumatic dilation than symptoms assessment. Gut. 2002;50:765–70.

    Article  PubMed  CAS  Google Scholar 

  24. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992;103:1732–8.

    PubMed  CAS  Google Scholar 

  25. Hulselmans M, Vanuytsel T, Degreef T, et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol. 2010;8:30–5.

    Article  PubMed  Google Scholar 

  26. Richter JE, Boeckxstaens GE. Management of achalasia: surgery or pneumatic dilation. Gut. 2011;6:869–76.

    Article  Google Scholar 

  27. Kadakia SC, Wong RKH. Graded pneumatic dilation using rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol. 1993;88:34–8.

    PubMed  CAS  Google Scholar 

  28. Richer JE. Update on the management of achalasia: balloons, surgery and drugs. Exp Rev Gastroenterol Hepatol. 2008;2:435–45.

    Article  Google Scholar 

  29. Zerbid F, Thetiot V, Richy F, et al. Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia. Am J Gastroenterol. 2006;101:692–7.

    Article  Google Scholar 

  30. O’Connor JB, Singer ME, Richter JE, et al. The cost-effectiveness of treatment strategies for achalasia. Dig Dis Sci. 2002;47:1516–25.

    Article  PubMed  Google Scholar 

  31. Karanicolas PJ, Smith SE, Gafni A, et al. The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia. Surg Endosc. 2007;21:1198–206.

    Article  PubMed  Google Scholar 

  32. Vantrappen G, Hellemans J, Deloof W, et al. Treatment of achalasia with pneumatic dilation. Gut. 1971;12:268–75.

    Article  PubMed  CAS  Google Scholar 

  33. Eckardt VF, Kanzler G, Westermeier T. Complications and their impact after pneumatic dilation for achalasia: prospective long-term follow-up study. Gastrointest Endosc. 1997;45:349–53.

    Article  PubMed  CAS  Google Scholar 

  34. Ghoshal UC, Kumar S, Saraswat VA, et al. Long-term follow-up after pneumatic dilation for achalasia of the cardia: factors associated with treatment failure and recurrence. Am J Gastroenterol. 2004;99:2304–10.

    Article  PubMed  CAS  Google Scholar 

  35. Vela M, Richter JE, Khandwala E, et al. The long-term efficacy of pneumatic dilation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol. 2006;4:580–7.

    Article  PubMed  Google Scholar 

  36. Kostic S, Kjellin A, Ruth M, et al. Pneumatic dilation or laparoscopic myotomy in the management of newly diagnosed idiopathic achalasia. World J Surg. 2007;31:470–8.

    Article  PubMed  CAS  Google Scholar 

  37. Metman EH, Lagasse JP, Alteroche L, et al. Risk factors for immediate complications after progressive pneumatic dilation for achalasia. Am J Gastroenterol. 1999;94:1179–85.

    Article  PubMed  CAS  Google Scholar 

  38. Guardino J, Vela M, Connor J, Richter JE. Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy. J Clin Gastroenterol. 2004;38:855–60.

    Article  PubMed  Google Scholar 

  39. Heller E. Extramukoese cardinplastik bein chronischen cardiopsasmus mit dilation des oesophagus. Mitt Grenzgeb Med Chir. 1914;27:141–5.

    Google Scholar 

  40. Vaezi MF, Richer JE. Current therapies for achalasia comparison and efficacy. J Clin Gastroenterol. 1998;27:21–35.

    Article  PubMed  CAS  Google Scholar 

  41. Pelligrini C, Wetter LA, Patti M, et al. Thoracoscopic esophagomyotomy. Initial experience with a new approach for achalasia. Ann Surg. 1992;216:291–6.

    Article  Google Scholar 

  42. Oelschlager BK, Chang L, Pellegrini CA. Improved outcomes after extended gastric myotomy for achalasia. Arch Surg. 2003;138:490–5.

    Article  PubMed  Google Scholar 

  43. Richards W, Torquati A, Holzman M, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405–15.

    Article  PubMed  Google Scholar 

  44. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments of achalasia. Ann Surg. 2009;249:45–57.

    Article  PubMed  Google Scholar 

  45. Constantini MI, Zanninotta G, Guirroli E, et al. The laparoscopic-Dor operation remains effective treatment for achalasia at a minimum of 6 years follow-up. Surg Endosc. 2005;19:345–51.

    Article  Google Scholar 

  46. Portale G, Constantini M, Rizzetto C, et al. Long term outcome of laparoscopic heller-Dor surgery for achalasia: possible detrimental role of previous endoscopic treatment. J Gastrointest Surg. 2005;9:1332–9.

    Article  PubMed  Google Scholar 

  47. Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally-invasive esophagomyotomy in 200 consecutive patients: factors influencing postoperative outcome. Ann Thorac Surg. 2008;85:1729–34.

    Article  PubMed  Google Scholar 

  48. Snyder CW, Burton RC, Brown LE, et al. Multiple preoperative endoscopic interventions are associated with worse outcome after laparoscopic Heller myotomy for achalasia. J Gastrointest Surg. 2010;14(4):2095–13.

    Google Scholar 

  49. Grockel I, Junginger T, Eckhardt V. Long-term results of conventional myotomy in patients with achalasia: a prospective 20 year analysis. Soc Surg Alimen Tract. 2006;10:1400–8.

    Google Scholar 

  50. Bonatti H, Hinder RA, Klocker J, et al. Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia. Am J Surg. 2005;190:874–8.

    Article  PubMed  Google Scholar 

  51. Sharp KW, Khaitan L, Scholz S, et al. 100 Consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg. 2002;235:631–9.

    Article  PubMed  Google Scholar 

  52. Patti MG, Feo CV, Diener U, et al. Laparoscopic Heller mytomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc. 1999;13:843–6.

    Article  PubMed  CAS  Google Scholar 

  53. Mineo TC, Pompeo E. Long-term outcome in Heller myotomy achalasia sigmoid esophagus. J Thorac Cardiovasc Surg. 2004;128:402–7.

    Article  PubMed  Google Scholar 

  54. Csendes A, Braghetto I, Burdiles P, Korn O, et al. Very late results of esophagomyotomy for patients with achalasia. Ann Surg. 2006;243(2):196–203.

    Article  PubMed  Google Scholar 

  55. Lopushinsky SR, Urbach DR. Pneumatic dilation and surgical myotomy for achalasia. J Am Med Assoc. 2006;296:2227–33.

    Article  CAS  Google Scholar 

  56. Shimi S, Nathanson LK, Cuschieri A. Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb. 1991;36:152–4.

    PubMed  CAS  Google Scholar 

  57. Boeckxstaens G, Annese V, Chaussade S, et al. Endoscopic pneumodilation versus laparoscopic Heller myotomy with Dor anti-reflux procedure for idiopathic achalasia. N Engl J Med. 2011;364:1807–16.

    Article  PubMed  CAS  Google Scholar 

  58. Hoogerwerf WA, Pasricha PJ. Pharmacologic therapy in treating achalasia. Gastrointest Endosc Clin North Am. 2001;11:311–23.

    CAS  Google Scholar 

  59. Bortolotti M, Mari C, Lopilato C, et al. Effects of sildenafil on esophageal motility of patients with idiopathic achalasia. Gastroenterology. 2000;118:253–7.

    Article  PubMed  CAS  Google Scholar 

  60. Annese V, Bassotti G, Coccia G, et al. A multicenter randomized study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. Gut. 2000;46:597–600.

    Article  PubMed  CAS  Google Scholar 

  61. Pasricha PJ, Rai R, Ravich WJ, et al. Botulinum toxin for achalasia: long-term outcome and predictor of response. Gastroenterology. 1996;110:1410–5.

    Article  PubMed  CAS  Google Scholar 

  62. Vaezi MJ, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic dilation in the treatment of achalasia: a randomized trial. Gut. 1999;44:231–9.

    Article  PubMed  CAS  Google Scholar 

  63. Fishman VM, Parkman HP, Schiano TD, et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. Am J Gastroenterol. 1996;91:1724–30.

    PubMed  CAS  Google Scholar 

  64. Mikaeli J, Fazel A, Montazeri G, et al. Randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for the treatment of achalasia. Aliment Pharmacol Ther. 2001;15:1389–96.

    Article  PubMed  CAS  Google Scholar 

  65. Panaccione R, Gregor JC, Reynolds RPE, et al. Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis. Gastrointest Endosc. 1999;50:492–8.

    Article  PubMed  CAS  Google Scholar 

  66. Ortega JA, Madureri V, Perez I. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc. 1980;26:8–10.

    Article  PubMed  CAS  Google Scholar 

  67. Pasricha PJ, Hawari R, Ahmed I, et al. Submuscosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–4.

    Article  PubMed  CAS  Google Scholar 

  68. Perretta S, Dallemagne B, Donnatelli G, et al. Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model. Gastrointest Endosc. 2011;73:111–6.

    Article  PubMed  Google Scholar 

  69. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–71.

    Article  PubMed  CAS  Google Scholar 

  70. Micci MA, Learish RD, Li H, et al. Neural stem cell expresses RET, produces nitric oxide and survives transplantation in the GI tract. Gastroenterology. 2001;121:7757–66.

    Article  Google Scholar 

  71. Kahrilas PJ, Dodds WJ, Hogan WJ. Effect of peristaltic dysfunction on esophageal volume clearance. Gastroenterology. 1988;94:73–80.

    PubMed  CAS  Google Scholar 

  72. Kahrilas PJ, Pandolfino JE. Ineffective esophageal peristalsis does not equate to GERD. Am J Gastroenterol. 2003;98:715–7.

    Article  PubMed  Google Scholar 

  73. Diener U, Patti MG, Molena D, et al. Esophageal dysmotility and gastroesophageal reflux disease. J Gastrointest Surg. 2001;5:260–5.

    Article  PubMed  CAS  Google Scholar 

  74. Tutuian R, Castell DO. Clarification of the esophageal function defect in patients with manometric ineffective esophageal motility studies using combined impedance-manometry. Clin Gastroenterol Hepatol. 2004;2:230–6.

    Article  PubMed  Google Scholar 

  75. Conchillo M, Nguyen NQ, Sansom M, et al. Multichannel intraluminal impedance monitoring in the evaluation of patients with non-obstructive dysphagia. Am J Gastroenterol. 2005;100:2624–32.

    Article  PubMed  Google Scholar 

  76. Leite LP, Johnson BT, Barrett J, et al. Ineffective esophageal motility: the primary finding in patients with non-specific esophageal motility disorders. Dig Dis Sci. 1997;42:1859–65.

    Article  PubMed  CAS  Google Scholar 

  77. Fouad YM, Katz PO, Hatlebakk JG, et al. Ineffective esophageal motility: the most common motility abnormality in patients with GERD-associated respiratory symptoms. Am J Gastroenterol. 1999;94:1464–7.

    Article  PubMed  CAS  Google Scholar 

  78. Lund RJ, Wetcher GJ, Raiser F, et al. Laparoscopic toupet for gastroesophageal reflux disease with poor esophageal body motility. J Gastrointest Surg. 1997;1:301–8.

    Article  PubMed  CAS  Google Scholar 

  79. Zhang X, Geboes K, Depoortere I, et al. Effect of repeated cycles of acute esophagitis and healing on esophageal peristalsis; time and length. Am J Physiol. 2005;288:G1339–46.

    CAS  Google Scholar 

  80. Singh P, Adamopoulos A, Taylor RH, et al. Oesophageal motor function before and after healing of oesophagitis. Gut. 1992;33:1590–6.

    Article  PubMed  CAS  Google Scholar 

  81. Fibbe C, Layer P, Keller J, et al. Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical and manometric study. Gastroenterology. 2001;121:5–14.

    Article  PubMed  CAS  Google Scholar 

  82. Cao W, Cheng L, Behar J, et al. Proinflammatory cytokines alter/reduce esophageal circular muscle ­contraction in experimental cat esophagitis. Am J Physiol Gastrointest Liver Physiol. 2004;287:G1131–9.

    Article  PubMed  CAS  Google Scholar 

  83. Rieder F, Cheng L, Harnett KM, et al. Gastroesophageal reflux disease-associated esophagitis induces endogenous cytokine production leading to otor abnormalities. Gastroenterology. 2007;132:154–65.

    Article  PubMed  CAS  Google Scholar 

  84. Corazziari E, Bontempo I, Anzini F. Effects of cisapride on distal esophageal motility in humans. Dig Dis Sci. 1989;34:1600–5.

    Article  PubMed  CAS  Google Scholar 

  85. Grande L, Lacima G, Ros E, et al. Lack of effect of metoclopramide and domperidone on esophageal peristalsis, and esophageal clearance in reflux esophagitis. A randomized, double-blind study. Dig Dis Sci. 1992;37:583–8.

    Article  PubMed  CAS  Google Scholar 

  86. Agrawal A, Hila A, Tutuian R, et al. Bethanechol improves smooth muscle function in patients with severe ineffective esophageal motility. J Clin Gastroenterol. 2007;41:366–70.

    Article  PubMed  CAS  Google Scholar 

  87. Grossi L, Ciccaglione AF, Marzio L. Effect of the 5-HT1 agonist sumatriptan on oesophageal motor patterns in patients with ineffective oesophageal motility. Neurogastroenterol Motil. 2003;15:9–14.

    Article  PubMed  CAS  Google Scholar 

  88. Montenovo M, Tatum RP, Figueredo, et al. Does combined multichannel intraluminal esophageal impedance and manometry predict post-operative dysphagia after laparoscopic nissen fundoplication? Dis Esophagus. 2009;22:656–63.

    Article  PubMed  CAS  Google Scholar 

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  1. Division of Digestive Diseases and Joy McCann Culverhouse Swallowing Center, University of South Florida, Tampa, FL, USA

    Joel E. Richter MD

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  1. Joel E. Richter MD
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Editors and Affiliations

  1. Div. Gastroenterology & Hepatology, Medical College of Wisconsin, West Wisconsin Avenue 9200, Milwaukee, 53226, Wisconsin, USA

    Reza Shaker

  2. , Dpt Otolaryngology/Head & Neck Surg., UC Davis Medical Center, Stockton Blvd. 2521, Sacramento, 95817, California, USA

    Peter C. Belafsky

  3. Ctr for Voice, Airway & Swallowing Disor, Department of Otolaryngology, Georgia Health Sciences University, 15th Street 1120, Augusta, 30912, Georgia, USA

    Gregory N. Postma

  4. , Dpt of Communication Sciences & Disorder, University of Wisconsin-Milwaukee, East Hartford Ave 2400, Milwaukee, 53201, Wisconsin, USA

    Caryn Easterling

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Richter, J.E. (2013). Achalasia and Ineffective Esophageal Motility. In: Shaker, R., Belafsky, P., Postma, G., Easterling, C. (eds) Principles of Deglutition. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-3794-9_39

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