Upper Esophageal Sphincter Abnormalities Are Strongly Predictive of Treatment Response in Patients with Achalasia

Abstract

Purpose: The introduction of high resolution esophageal manometry (HRM) has allowed the ability to assess the upper esophageal sphincter (UES). However, UES abnormalities are often interpreted as incidental findings with no defined significance. We hypothesized that UES abnormalities have clinical significance and may predict treatment response in patients with achalasia. Methods: We performed a retrospective study of 41 consecutive patients referred for HRM with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of 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 profi les. 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, irrespective of the type of treatment received or achalasia sub-type. Future prospective studies are needed to determine whether specific UES abnormalities have additional prognostic value and to further delineate the underlying mechanism between UES dysfunction with achalasia in order to optimize therapeutic treatment modalities.