Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia

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Abstract

Timed barium swallow (TBS) assesses esophageal emptying in patients with achalasia and is considered the standard workup for patients with dysphagia. Our aim was to determine the usefulness of TBS in differentiating patients with achalasia (type 1-3), esophagogastric junction outflow obstruction (EGJOO), and non-achalasia dysphagia.

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Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography.

André Smout, Peter Kahrilas, John E Pandolfino … (2012)

The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into clinical practice. The Chicago Classification has been an evolutionary process, molded first by published evidence pertinent to the clinical interpretation of high resolution manometry (HRM) studies and secondarily by group experience when suitable evidence is lacking. This publication summarizes the state of our knowledge as of the most recent meeting of the International High Resolution Manometry Working Group in Ascona, Switzerland in April 2011. The prior iteration of the Chicago Classification was updated through a process of literature analysis and discussion. The major changes in this document from the prior iteration are largely attributable to research studies published since the prior iteration, in many cases research conducted in response to prior deliberations of the International High Resolution Manometry Working Group. The classification now includes criteria for subtyping achalasia, EGJ outflow obstruction, motility disorders not observed in normal subjects (Distal esophageal spasm, Hypercontractile esophagus, and Absent peristalsis), and statistically defined peristaltic abnormalities (Weak peristalsis, Frequent failed peristalsis, Rapid contractions with normal latency, and Hypertensive peristalsis). The Chicago Classification is an algorithmic scheme for diagnosis of esophageal motility disorders from clinical EPT studies. Moving forward, we anticipate continuing this process with increased emphasis placed on natural history studies and outcome data based on the classification. © 2012 Blackwell Publishing Ltd.

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Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment.

M F Vaezi, M E Baker, E Achkar … (2002)

Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium. We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates. Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence. Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months). (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.

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Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia.

John R Scherer, Monika A Kwiatek, Nathanial J Soper … (2009)

Some patients with suspected achalasia are found on manometry to have preserved peristalsis, thereby excluding that diagnosis. This study evaluated a series of such patients with functional esophagogastric junction (EGJ) obstruction. Among 1,000 consecutive high-resolution manometry studies, 16 patients had functional EGJ obstruction characterized by impaired EGJ relaxation and intact peristalsis. Eight patients with post-fundoplication dysphagia and similarly impaired EGJ relaxation were studied as a comparator group with mechanical obstruction. Intrabolus pressure (IBP) was measured 1 cm proximal to the EGJ. Sixty-eight normal controls were used to define normal IBP. Patients' clinical features were evaluated. Functional EGJ obstruction patients presented with dysphagia (96%) and/or chest pain (42%). IBP was significantly elevated in idiopathic and post-fundoplication dysphagia patients versus controls. Among the idiopathic EGJ obstruction group treated with pneumatic dilation, BoTox(TM), or Heller myotomy, only the three treated with Heller myotomy responded well. Among the post-fundoplication dysphagia patients, three of four responded well to redo operations. Functional EGJ obstruction is characterized by pressure topography metrics demonstrating EGJ outflow obstruction of magnitude comparable to that seen with post-fundoplication dysphagia. Affected patients experience dysphagia and/or chest pain. In some cases, functional EGJ obstruction may represent an incomplete achalasia syndrome.

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Author and article information

Journal

Title: The American Journal of Gastroenterology

Abbreviated Title: Am J Gastroenterol

Publisher: Springer Nature America, Inc

ISSN (Print): 0002-9270

ISSN (Electronic): 1572-0241

Publication date Created: December 19 2017

Publication date Created: February 2018

Publication date (Electronic): December 19 2017

Publication date (Print): February 2018

Volume: 113

Issue: 2

Pages: 196-203

Article

DOI: 10.1038/ajg.2017.370

PubMed ID: 29257145

SO-VID: 0adad821-004e-4834-9444-7d8296901d33

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Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia

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New directions in predictive processing

Most cited references 10

Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography.

Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment.

Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia.

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