Tu1165 Clinical and Endoscopic Characteristics Can Help Distinguish Malignancy-Associated Pseudoachalasia From Idiopathic Achalasia

Abstract

Pseudoachalasia is a condition in which clinical and manometric signs of idiopathic achalasia are mimicked by another abnormality, most often a malignancy. An underlying malignancy should be recognized early to prevent delay in appropriate treatment. The aim of our study was to identify characteristics that suggest potential pseudoachalasia caused by malignancy and warrant additional investigation. Methods: All patients newly diagnosed with achalasia by manometry between January 2000 and November 2014 were included. Patients who were afterwards found to have an underlying malignancy were classified as having pseudoachalasia. Clinical (symptoms and Eckardt score), manometric, endoscopic and radiological findings were reviewed and compared between pseudoachalasia versus achalasia. Results: In total 270 patients with achalasia were included (148 male, median age 51 (38-63) (median (IQR)). Malignant pseudoachalasia was diagnosed in 16 patients (5.9%, 12 male) and caused by esophageal adenocarcinoma (n=5), esophageal squamous cell carcinoma (n=3), gastric adenocarcinoma (n=5), pancreatic adenocarcinoma (n=2) or paraneoplastic syndrome by mediastinal lymphoma (n=1). The underlying malignancy was found at EUS (19%), second or third endoscopy with biopsies (25%), CT scan (31%) or during a treatment session (25%; 2x Heller myotomy, 2x pneumodilation). In 3/16 of the patients a CT scan after achalasia treatment, performed because of quick recurrence of symptoms, eventually showed the malignancy. Patients with pseudoachalasia were older at time of diagnosis (66 (53-72) vs 51 (38-63), p .05). Manometries in both groups showed aperistalsis and dysrelaxation of the LES, with no difference in LES pressure (32 (21-35) mmHg vs 25 (18-34) mmHg, p >.05). In 91% of patients with pseudoachalasia a barium esophagogram was performed and in 77% it was typical of achalasia, showing stasis and/or luminal dilation, compared to 93% in achalasia (p >.05). In 56% of endoscopies in pseudoachalasia the LES was difficult or even impossible to pass, compared to 23% in the achalasia group (p 60 years with a clinical history <12 months had a 35 times higher chance of having pseudo-achalasia than those under 60 years and a clinical history longer than 12 months. Conclusion: Advanced age, short clinical history, considerable weight loss and difficulty in passing the LES during endoscopy are characteristics that should arouse a higher suspicion of pseudoachalasia and warrant additional investigations such as CT and EUS.