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Gastrointestinal Imaging |
1 From the Departments of Radiology (R.A., M.S.L., S.E.R., I.L., R.O.R.) and Medicine (D.A.K.), Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received April 22, 2004; revision requested June 29; revision received July 30; accepted September 28. Address correspondence to M.S.L. (e-mail: marc.levine@uphs.upenn.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: The institutional review board approved this retrospective study and did not require informed consent. A search of radiology and manometry records identified 21 patients (12 men, nine women; mean age, 52.4 years) with achalasia depicted on barium esophagograms who had undergone manometric examinations and met the inclusion criteria. Radiologic reports and images were reviewed for presence or absence of primary peristalsis, impaired LES opening, esophageal dilatation, delayed emptying of barium, and nonperistaltic contractions. Manometry reports were reviewed for presence or absence of peristalsis or simultaneous esophageal contractions. Resting and residual LES pressures were recorded to determine whether LES relaxation was complete or incomplete. Medical records were reviewed to determine clinical presentation and follow-up (treatment and patient course), and radiographic files were reviewed to determine radiographic findings at follow-up examinations. Clinical characteristics (eg, age, dysphagia, and weight loss) were correlated with LES relaxation at manometry. Data were analyzed statistically with Fisher exact and Wilcoxon rank sum testing.
RESULTS: All 21 patients with radiographic findings of achalasia had aperistalsis at manometry. Fourteen patients (67%) had incomplete LES relaxation at manometry during swallowing, and seven (33%) had complete LES relaxation. There were no significant differences between patients with complete LES relaxation and those with incomplete LES relaxation in mean age (P = .59), duration of dysphagia (P = .18), or weight loss (P > .99). Clinical follow-up findings were available for six patients with complete LES relaxation at manometry and 10 with incomplete relaxation. Symptoms resolved after treatment in all six patients with complete LES relaxation. Six (60%) of 10 patients with incomplete LES relaxation had resolution of symptoms after treatment, and four (40%) had substantial improvement.
CONCLUSION: These data suggest that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry. If radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Despite these classic radiographic and manometric findings in achalasia, several previous investigators have reported a subset of patients with findings of achalasia at barium examination in whom manometry revealed complete LES relaxation during swallowing (7–10). The authors of these studies concluded that normal LES relaxation at manometry does not preclude a diagnosis of achalasia when patients present with characteristic clinical and radiographic features of this condition. Such data raise questions about the respective roles of barium studies and manometry in the diagnosis of achalasia. Thus, the purpose of our study was to evaluate retrospectively the presence of complete LES relaxation at manometry in patients with achalasia depicted on barium esophagograms.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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A computerized search of the radiology database at our university hospital for a 6-year period from January 1998 through December 2003 revealed data for 190 patients who had undergone barium examinations and for whom the final diagnosis in the radiologic reports was achalasia. Achalasia is defined radiographically as the absence of primary peristalsis in the body of the esophagus during all swallows, with tapered, beaklike narrowing of the distal esophagus at or adjacent to the gastroesophageal junction (3,5,6). Fifty-six (29%) of the 190 patients also underwent esophageal manometry within 1 year of the barium studies. Thirty-five (62%) of these 56 patients were excluded from analysis for the following reasons: (a) previous surgical procedures (eg, Heller myotomy) had been performed for treatment of achalasia in six patients; (b) endoscopic procedures (eg, endoscopic balloon dilation or botulinum toxin injection) had been performed for treatment of achalasia between the barium studies and manometry in two patients; (c) the radiographic studies had been performed with water-soluble contrast agents to rule out perforation immediately after any form of treatment for achalasia in eight patients; (d) medical records revealed secondary rather than primary achalasia in three patients; and (e) no medical records were available in 16 patients.
The remaining 21 patients comprised our study group. Twelve patients (57%) were men, and nine (43%) were women. The mean age of the 21 patients was 52.4 years (range, 19–85 years), the mean interval between the barium studies and manometry was 2.4 months (range, 1 day to 11 months), and the median interval was 1.5 months. The barium studies were performed before manometry in 14 patients and after manometry in seven.
Imaging
Sixteen (76%) of the 21 patients underwent esophagography at our institution. The studies included left posterior oblique double-contrast views obtained with the patient upright and a 250% wt/vol high-density barium suspension (E-Z-HD; E-Z-Em, Westbury, NY) and/or right anterior oblique single-contrast views obtained with the patient prone and a 50% wt/vol barium suspension (Entrobar; Lafayette Pharmaceuticals, Lafayette, Ind). As part of the examination, patients were asked to take multiple discrete swallows in the prone, right anterior oblique position so that esophageal motility could be evaluated, unless markedly delayed emptying of barium from the esophagus in the upright position precluded such repositioning. All of these studies were performed by residents or fellows supervised by gastrointestinal radiologists or by one of three attending gastrointestinal radiologists, and all were interpreted by the three gastrointestinal radiologists (M.S.L., S.E.R., and I.L., with 22, 20, and 29 years of experience, respectively). The remaining five of the 21 patients underwent barium studies at outside hospitals and had detailed radiographic reports in their medical records. The radiographic images from these five barium studies and two of the 16 performed at our hospital were not available for review.
Image and Report Review
The original radiologic reports from all 21 barium studies and the images from 14 of them were reviewed simultaneously by one author (M.S.L.) without knowledge of the specific clinical or manometric findings. In all 21 cases, he recorded whether or not primary peristalsis was absent in the esophagus intermittently or for all swallows and whether or not there was tapered, beaklike narrowing of the distal esophagus, a well-known radiographic sign of impaired LES opening on barium esophagograms in patients with achalasia (3,5,6). Esophageal dilatation, delayed emptying of barium, and nonperistaltic contractions were also noted. Although the examinations generally were not recorded on videotape, the radiologic reports provided a relatively detailed assessment of esophageal motility, specifically stating whether primary peristalsis and features of LES dysfunction were present or absent. However, the reports mentioned nonperistaltic contractions, esophageal dilatation, or delayed emptying of barium only when these abnormalities were present on barium esophagograms, so they were assumed to be absent unless depicted on the images or described in the reports.
Thirteen patients (62%) underwent follow-up radiographic examinations with water-soluble contrast material (diatrizoate meglumine and diatrizoate sodium [Gastroview; Mallinckrodt, St Louis, Mo]) (nine patients) or barium (four patients) after endoscopic or surgical treatment of their achalasia. The studies with water-soluble contrast agents were performed within 3 days of treatment, and the barium studies were performed a mean interval of 7.6 months after treatment (range, 2 months to 6.5 years). The radiologic reports from these studies were reviewed to assess the response to treatment.
Manometry and Report Review
In all 21 patients, esophageal manometry was performed at our hospital by a gastroenterologist with 21 years of experience (D.A.K.) who used a solid-state intraluminal transducer assembly (Konigsberg Instruments, Pasadena, Calif). The Konigsberg catheter was placed in the stomach with a transnasal approach. Gastric (ie, intraabdominal) positioning of the pressure transducers was confirmed by a rise in pressure during the inspiratory phase of respiration. The patient was then placed in a sitting position, and the LES was identified on the distal circumferential transducer tracing by using the station pull-through technique. Catheter withdrawal was continued until the pressure inversion point was identified. LES pressure measurements were obtained distal to the inversion point. Esophageal body motility was then assessed after the distal transducer was positioned 3 cm above the proximal border of the LES. The patient performed a series of 10 wet swallows while pressures were recorded 3, 8, and 13 cm above the LES. The resting pressure and length of the LES were also measured according to standard techniques with the same transducer assembly.
One of the authors (R.A.) reviewed the manometry reports for these 21 patients to determine whether esophageal peristalsis was absent in the esophagus intermittently or for all swallows and whether there were simultaneous contractions in the esophagus. LES resting pressures and residual pressures during swallowing were also recorded. As described previously (11), LES resting pressures were considered high if they exceeded 45 mm Hg, and LES relaxation was considered incomplete if residual pressures were 8 mm Hg or higher during swallowing.
Medical Records Review
Medical records subsequently were reviewed by one author (R.A.) to determine the clinical presentation and follow-up (ie, treatment and patient course). Resolution of symptoms after treatment was considered the reference standard for the presence of achalasia. Clinical characteristics of these 21 patients (age, frequency and mean duration of dysphagia, frequency and mean amount of weight loss, and frequency of other presenting symptoms) were also correlated with LES relaxation at manometry.
Statistical Analysis
A statistical analysis comparing patients with complete and those with incomplete LES relaxation was performed by means of a Fisher exact test for categorical variables (frequency of dysphagia, chest pain, heartburn, regurgitation, respiratory symptoms, and weight loss; number of patients with a hypertensive LES; number of patients with prior treatment; and average number of treatments) and a Wilcoxon rank sum test for continuous variables (mean age, mean duration of dysphagia, mean weight loss, mean LES resting pressure, and mean LES residual pressure) (S Plus 4.0; Insightful, Seattle, Wash). P values less than .05 were considered to indicate a statistically significant difference.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Radiographic Findings
In all 21 patients (100%), primary peristalsis was absent in the body of the esophagus during all swallows of barium. All patients also had an impaired LES opening, manifested by tapered, beaklike narrowing of the distal esophagus at or adjacent to the gastroesophageal junction, and all had varying degrees of esophageal dilatation with delayed emptying of barium from the esophagus (Figs 1, 2). Eight patients (38%) had occasional weak nonperistaltic contractions.
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The mean LES residual pressure was 16.3 mm Hg (range, 8.6–31.0 mm Hg) in the 14 patients with incomplete LES relaxation during swallowing and 3.4 mm Hg (range, –2.2 to 5.5 mm Hg) in the seven patients with complete LES relaxation (P = .001). The mean LES resting pressure was 45.5 mm Hg (range, 12.3–88.0 mm Hg) in the 14 patients with incomplete LES relaxation during swallowing and 25 mm Hg (range, 12.0–45.0 mm Hg) in the seven with complete LES relaxation—a significant difference (P = .01). Seven (50%) of the 14 patients with incomplete LES relaxation had a hypertensive sphincter, and seven (50%) had a normotensive sphincter, whereas all seven patients (100%) with complete LES relaxation had a normotensive sphincter (P = .047). Thus, seven (33%) of the 21 patients with achalasia seen on barium esophagograms had normal LES function at manometry (Figs 1, 2). The manometric findings in patients with complete and patients with incomplete LES relaxation during swallowing are summarized in the Table.
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Clinical Follow-up
Twenty (95%) of the 21 patients underwent endoscopic or surgical treatment for achalasia after the barium and manometric studies. All seven patients with complete LES relaxation at manometry underwent treatment, which involved botulinum toxin injections (n = 1), Heller myotomy (n = 2), botulinum toxin injections and Heller myotomy (n = 3), or botulinum toxin injections and balloon dilation followed by Heller myotomy (n = 1). Thirteen (93%) of the 14 patients with incomplete LES relaxation at manometry underwent treatment, which involved botulinum toxin injections (n = 3), balloon dilation (n = 3), Heller myotomy (n = 2), botulinum toxin injections and Heller myotomy (n = 3), balloon dilation and Heller myotomy (n = 1), or botulinum toxin injections, balloon dilation, and Heller myotomy (n = 1).
Clinical follow-up findings were available for six (86%) of the seven patients with complete LES relaxation at manometry and for 10 (71%) of the 14 patients with incomplete LES relaxation. Symptoms resolved after treatment in all six patients with complete LES relaxation and in six (60%) of the 10 patients with incomplete LES relaxation. The remaining four patients with incomplete LES relaxation had substantial improvement in symptoms. Symptoms resolved in all 13 patients in both groups who underwent Heller myotomy. The average number of treatments needed for resolution or substantial improvement of symptoms was 3.0 (range, 1–9) in the patients with complete LES relaxation versus 2.2 (range, 1–4) in those with incomplete LES relaxation (P = .38).
Radiographic Follow-up
All nine patients who underwent follow-up radiographic examinations with water-soluble contrast media within days after endoscopic or surgical treatment of achalasia were found to have decreased narrowing at the gastroesophageal junction, with improved emptying of contrast material from the esophagus. Four other patients in whom follow-up barium examinations were performed months to years after treatment were also found to have decreased narrowing of the distal esophagus and improved emptying of barium from the esophagus.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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In two of the earlier studies that revealed complete LES relaxation in patients with achalasia, patients with normal LES function at manometry were younger and had less weight loss, a shorter duration of dysphagia, and less esophageal dilatation on barium esophagograms than those with incomplete LES relaxation (7,8). The authors therefore concluded that such patients had a less advanced form of achalasia. In our study, however, there were no significant differences between these groups in mean age, mean weight loss, or mean duration of dysphagia. Another study also revealed no significant differences between the two groups in any of these clinical parameters (9). Such findings therefore do not corroborate the hypothesis that complete LES relaxation at manometry is a characteristic of early achalasia.
The previous studies did not reveal significant differences in LES resting pressures between patients with achalasia and complete LES relaxation at manometry and those with achalasia and incomplete LES relaxation (7,8). In our study, however, patients with complete LES relaxation during swallowing had a significantly lower mean LES resting pressure than those with incomplete LES relaxation (P = .01) and were significantly more likely to have a normotensive sphincter (P = .047). Our findings indicate that a substantial number of patients with achalasia have complete LES relaxation during swallowing and normal LES resting pressures with no evidence of LES dysfunction at manometry. The patients with complete and those with incomplete LES relaxation at manometry underwent comparable numbers of treatment procedures (suggesting similar severity of disease), and both groups showed excellent responses to treatment, with resolution or improvement of symptoms, regardless of the degree of LES dysfunction at manometry.
These data raise questions about the role of manometry in patients with long-standing dysphagia who are suspected of having achalasia. If the barium study reveals typical findings of achalasia, our experience suggests that such patients can be treated without a need for manometry, avoiding the cost, inconvenience, and discomfort of this procedure. Nevertheless, our study was limited by an inability to identify patients with achalasia diagnosed at manometry who had false-negative esophagograms. As a result, manometry still may be required to establish the diagnosis in patients clinically suspected of having achalasia who have equivocal or even negative radiographic results.
Other conditions occasionally can mimic the findings of primary achalasia on barium esophagograms. The most important condition is secondary achalasia caused by malignant tumor at the gastroesophageal junction or, less commonly, by benign conditions such as Chagas disease (12). In patients with secondary achalasia, however, the narrowed segment tends to be longer than that in primary achalasia (extending more than 3.5 cm above the gastroesophageal junction) and is frequently associated with nodularity, ulceration, or asymmetry (12,13). A smooth, tapered peptic stricture in the distal part of the esophagus may also resemble the beaklike narrowing of achalasia, but most patients with peptic strictures have hiatal hernias and normal esophageal peristalsis. Thus, it usually is possible to differentiate these conditions from primary achalasia on the basis of the radiographic findings.
It is important to recognize the inherent limitations of our retrospective study, which included selection bias and possible inaccurate reporting of symptoms in the medical records. Because of the relatively small number of patients who underwent manometry, manometric correlation was not possible for most patients with achalasia diagnosed at radiography, creating an additional selection bias. We also had to rely on the original radiographic reports for characterization of the motility findings because the fluoroscopic findings generally were not recorded on videotape at the time of these examinations. Unfortunately, some patients had a relatively long interval between the barium studies and manometry, but achalasia is a chronic disease that gradually evolves over time, minimizing the effect of this bias. Finally, our failure to detect significant differences for some parameters between patients with complete LES relaxation and those with incomplete relaxation at manometry could have been related to inadequate sample sizes, a common methodologic problem in studies of this type (14). Because of our study limitations, a prospective investigation of a large series of patients suspected of having achalasia is needed, with barium studies and manometry performed in all cases to elucidate further the respective roles of these examinations.
In conclusion, we found that one-third of patients with achalasia depicted on barium studies had normal LES relaxation at manometry, but there were no significant differences in the clinical presentation between those with complete and those with incomplete LES relaxation during swallowing. All patients with achalasia on barium esophagograms had an excellent response to treatment, regardless of the degree of LES relaxation at manometry. Our experience suggests that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry. If the radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis.
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FOOTNOTES |
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Authors stated no financial relationship to disclose.
Author contributions: Guarantor of integrity of entire study, M.S.L.; study concepts, R.A., M.S.L., S.E.R., D.A.K.; study design, R.A., M.S.L.; literature research, R.A.; clinical studies, M.S.L., S.E.R., I.L., D.A.K.; data acquisition, R.A., M.S.L., S.E.R.; data analysis/interpretation, all authors; statistical analysis, R.O.R.; manuscript preparation and definition of intellectual content, R.A., M.S.L.; manuscript editing, M.S.L., S.E.R., I.L., R.O.R., D.A.K.; manuscript revision/review and final version approval, all authors
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  M. S. Levine, S. E. Rubesin, and I. Laufer Barium Studies in Modern Radiology: Do They Have a Role? Radiology, January 1, 2009; 250(1): 18 - 22. [Full Text] [PDF]
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