Retrospective Study
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World J Clin Cases. Sep 16, 2014; 2(9): 448-454
Published online Sep 16, 2014. doi: 10.12998/wjcc.v2.i9.448
Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia
Simon C Mathews, Maria Ciarleglio, Yamile Haito Chavez, John O Clarke, Ellen Stein, Bani Chander Roland
Simon C Mathews, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
Maria Ciarleglio, School of Public Health, Yale University, New Haven, CT 06520, United States
Yamile Haito Chavez, John O Clarke, Ellen Stein, Bani Chander Roland, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
Author contributions: Chander Roland B designed the study; Chander Roland B and Chavez YH enrolled patients, collected data, and performed chart review; Ciarleglio M performed the statistical analysis; Mathews S and Chander Roland B wrote the manuscript; Stein E, Clarke J, and Chander Roland B interpreted manometry; Stein E and Clarke J provided critical review of manuscript.
Correspondence to: Bani Chander Roland, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue A-501, Baltimore, MD 21224, United States. bchande1@jhmi.edu
Telephone: +1-410-5508124 Fax: +1-410-5507861
Received: January 5, 2014
Revised: March 29, 2014
Accepted: April 28, 2014
Published online: September 16, 2014
Processing time: 60 Days and 9.9 Hours
Abstract

AIM: To investigate the relationship between upper esophageal sphincter abnormalities achalasia treatment

METHODS: We performed a retrospective study of 41 consecutive patients referred for high resolution esophageal manometry with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of Upper esophageal sphincter (UES) abnormality, and clinical and manometric profiles were compared. Correlation between UES abnormality and sub-type (i.e., hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness, psychiatric illness, surgical history, dominant presenting symptom, treatment type, age and gender were also evaluated.

RESULTS: Among all 41 patients, 24 (58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profiles. Among those with UES abnormalities, the majority were either hypertensive (41.67%) or had impaired relaxation (37.5%) as compared to hypotensive (20.83%), although this did not reach statistical significance (P = 0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority (78.57%) had good treatment response, as compared to 21.43% with poor treatment response (P = 0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality (P = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality (P = 0.017).

CONCLUSION: The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function.

Keywords: Upper esophageal sphincter; Achalasia; Motility; Dysphagia; Esophageal disorders

Core tip: Our study highlights how the presence of Upper esophageal sphincter (UES) abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function, irrespective of the type of treatment received or achalasia sub-type. We believe this finding is novel and represents an opportunity to more fully characterize upper esophageal sphincter pathology in a clinical context.