Progression of Jackhammer Esophagus to Type III Achalasia and Improvement After Extended Myotomy

Repetitive retrograde contractions (RRCs) in response to sustained esophageal distension are a distinct contractility pattern observed with functional luminal imaging probe (FLIP) panometry that are common in type III (spastic) achalasia. RRCs are hypothesized to be indicative of either impaired inhibitory innervation or esophageal outflow obstruction. We aimed to apply FLIP panometry to patients with postfundoplication dysphagia (a model of esophageal obstruction) to explore mechanisms behind RRCs. Adult patients with dysphagia after Nissen fundoplication ( n = 32) or type III achalasia ( n = 25) were evaluated with high-resolution manometry (HRM) and upper endoscopy with FLIP. HRM studies were assessed for outflow obstruction and spastic features: premature contractility, hypercontractility, and impaired deglutitive inhibition during multiple-rapid swallows. FLIP studies were analyzed to determine the esophagogastric junction (EGJ)-distensibility index and contractility pattern, including RRCs. Barium esophagram was evaluated when available. RRCs were present in 8/32 (25%) fundoplication and 19/25 (76%) achalasia patients ( P < 0.001). EGJ outflow obstruction was detected in 21 (67%) fundoplication patients by HRM, FLIP, or esophagram [6 (29%) had RRCs]. On HRM, none of the fundoplication patients had premature contractility, whereas 3/4 with defective inhibition on multiple-rapid swallows and 2/4 with hypercontractility had RRCs. Regression analysis demonstrated HRM with spastic features, but not esophageal outflow obstruction, as a predictor for RRCs. RRCs in response to sustained esophageal distension appear to be a manifestation of spastic esophageal motility. Although future study to further clarify the significance of RRCs is needed, RRCs on FLIP panometry should prompt evaluation for a major motor disorder. NEW & NOTEWORTHY Repetitive retrograde contractions (RRCs) are a common response to sustained esophageal distension among spastic achalasia patients when evaluated with the functional luminal imaging probe. We evaluated patients with postfundoplication dysphagia, i.e., patients with suspected mechanical obstruction, and found that RRCs occasionally occurred among postfundoplication patients, but often in association with manometric features of esophageal neuromuscular imbalance. Thus, RRCs appear to be a manifestation of spastic esophageal dysmotility, likely from neural imbalance resulting in excess excitation.

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Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

Surgical Endoscopy ◽

10.1007/s00464-018-6356-0 ◽

2018 ◽

Vol 33 (3) ◽

pp. 886-894 ◽

Cited By ~ 10

Author(s):

Erica D. Kane ◽

Vikram Budhraja ◽

David J. Desilets ◽

John R. Romanelli

Keyword(s):

High Resolution ◽

Esophageal Manometry ◽

Type Iii ◽

Per Oral Endoscopic Myotomy ◽

Endoscopic Myotomy ◽

Type Iii Achalasia ◽

Per Oral

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Per-Oral Endoscopic Myotomy Reverses Aperistalsis in Type III Achalasia

The American Journal of Gastroenterology ◽

10.14309/00000434-201810001-02963 ◽

2018 ◽

Vol 113 (Supplement) ◽

pp. S1631-S1632

Author(s):

Komal Thind ◽

Guryadav Dhillon ◽

Siva Raja ◽

Prasanthi N. Thota ◽

Madhusudhan R. Sanaka

Keyword(s):

Type Iii ◽

Per Oral Endoscopic Myotomy ◽

Endoscopic Myotomy ◽

Type Iii Achalasia ◽

Per Oral

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PS01.006: ROLE OF HIGH RESOLUSION MANOMETRY FOR DIAGNOSIS OF ESOPHAGEAL SPASTIC DISORDERS

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.006 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 51-51

Author(s):

Hisako Kameyama ◽

Tatsuhiro Masaoka ◽

Tsuyoshi Yamane ◽

Hiroya Takeuchi ◽

Hirofumi Kawakubo ◽

...

Keyword(s):

Chest Pain ◽

Conflicts Of Interest ◽

Gastrointestinal Surgery ◽

Diagnostic Strategy ◽

Type I ◽

Type Ii ◽

Type Iii ◽

Esophageal Spasm ◽

Refractory Gerd ◽

Type Iii Achalasia

Abstract Background Esophageal spastic disorders such as spastic (Type III) achalasia, distal esophageal spasm, and Jackhammer esophagus are rare clinical condition. Moreover, symptoms associated with esophageal spastic disorders such as dysphagia, chest pain, regurgitation, and heartburn is not specific to esophageal spastic disorders (Gastroenterol Clin North Am. 42:27–43, 2013.). Therefore, it is difficult to diagnose esophageal spastic disorders from symptoms. The aim of this study is to clarify diagnostic strategy for esophageal spastic disorders. Methods Patients who underwent all of esophagogastroduodenoscopy (EGD), High resolution manometry (HRM: Starlet®)) and esophagography in our Hospital for evaluation of symptoms such as dysphagia, chest pain, regurgitation, and heartburn from November 2013 to November 2017 were involved in the study. After approval by the research ethical committee (No.20150081), we retrospectively reviewed the clinical findings of these patients. Based on the Chicago classification (CC) v3.0 (Neurogastroenterol Motil. 27:160–174, 2015), findings obtained by HRM were classified. Patients who had past history of upper-gastrointestinal surgery were excluded from analysis. Results 174 patients (Mean age of 58.6 ± 15.4; 70male) were finally analyzed. Based on findings obtained by HRM, patients were classified as 25 achalasia, 15 Jackhammer esophagus, 0 distal esophageal spasm, 25 Esophagogastric junction outflow obstruction, 25 weak peristalsis, 6 failed peristalsis, 78 normal. Moreover, 23 patients with achalasia were classified as 8 Type I, 13 Type II, 4 Type III. In each subtype of achalasia, prevalence of esophageal dilation in EGD was 100%, 85%, 0%, respectively. In each subtype of achalasia, prevalence of liquid pool in esophagus in EGD was 100%, 69%, 0%, respectively. In esophagography, Compared with no findings group (15.5 ± 4.3cm), diameter of esophagus in patients with Type III achalasia(12.3 ± 4.8cm) were comparable, however that in patients with Type I(38.9 ± 18.6cm, P < 0.05) or Type II(32.0 ± 10.4cm, P < 0.01) achalasia were significantly wider. In patients with Jackhammer esophagus, prevalence of ring contractions in EGD and prevalence of corkscrew esophagus in esophagography were 33% and 13%, respectively. Conclusion With only EGD and esophagography, it was difficult to find visible findings which suggest esophageal spastic disorders. This suggests efficacy of HRM for diagnosis of this disorder and possibility of hidden esophageal spastic disorders in patients presumed as refractory GERD. Disclosure All authors have declared no conflicts of interest.

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