title: Esophageal contractions in type 3 achalasia esophagus: simultaneous or peristaltic?
abstract: Absence of peristalsis and impaired relaxation of lower esophageal sphincter are the hallmarks of achalasia esophagus. Based on the pressurization patterns, achalasia has been subdivided into three subtypes. The goal of our study was to evaluate the esophageal contraction pattern and bolus clearance in type 3 achalasia esophagus. High-resolution manometry (HRM) recordings of all patients diagnosed with achalasia esophagus in our center between the years 2011 and 2013 were reviewed. Recordings of 36 patients with type 3 achalasia were analyzed for the characteristics of swallow-induced "simultaneous esophageal contraction." The HRM impedance recordings of 14 additional patients with type 3 achalasia were analyzed for bolus clearance from the impedance recording. Finally, the HRM impedance along with intraluminal ultrasound imaging was conducted in six patients to further characterize the simultaneous esophageal contractions. Among 187 achalasia patients, 30 were type 1, 121 type 2, and 36 type 3. A total of 434 swallows evaluated in type 3 achalasia patients revealed that 95% of the swallow-induced contractions met criteria for simultaneous esophageal contraction, based on the onset of contraction. Interestingly, the peak and termination of the majority of simultaneous esophageal contractions were sequential. The HRM impedance revealed that 94% of the "simultaneous contractions" were associated with complete bolus clearance. Ultrasound image analysis revealed that baseline muscle thickness of patients in type 3 achalasia is larger than normal but the pattern of axial shortening is similar to that in normal subjects. The majority of esophageal contractions in type 3 achalasia are not true simultaneous contractions because the peak and termination of contraction are sequential and they are associated with complete bolus clearance.
authors.affiliation: Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California; and Department of Internal Medicine, Division of Gastroenterology, College of Medicine, The Catholic University of Korea, Seoul, Korea.
authors.forename: Tae Ho
authors.initials: TH
authors.lastname: Kim
authors.affiliation: Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California; and.
authors.forename: Nirali
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California; and.
authors.forename: Melissa
authors.initials: M
authors.lastname: Ledgerwood-Lee
authors.affiliation: Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California; and rmittal@ucsd.edu.
authors.forename: Ravinder K
authors.initials: RK
authors.lastname: Mittal
mesh_terms: D016022:Case-Control Studies; D003679:Deglutition; D004931:Esophageal Achalasia / Q000000981:diagnostic imaging / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction; D010528:Peristalsis
keywords: achalasia esophagus; esophageal peristalsis; multiple intraluminal esophageal impedance; type 3 achalasia; ultrasound imaging of the esophagus