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Symptom Severity and Physiological Measurements in Achalasia
Daniel J. Ross1, Joel Richter2, Vic Velanovich*1
1Surgery, University of South Florida, Tampa, FL; 2Medicine, University of South Florida, Tampa, FL
Background: The diagnosis of achalasia is generally made based on patient symptoms, the appearance of the esophagus on endoscopy and barium esophagogram, and esophageal manometry. In addition, timed barium esophagography can give useful information on the clearance of liquid barium over a 10 minute period and the passage of a barium tablet. What is unclear is how well these physiological measurements of esophageal function correlate with patient perceived symptoms. Our hypothesis is that more severe physiological derangements as measured by high resolution manometry and timed barium esophagography will correlate with more severe patient-perceived symptoms.
Methods: Patients referred for possible surgical treatment of achalasia were assessed preoperatively in the following manner. All were clinically evaluated by a gastroenterologist and surgeon. In addition to history and physical examination, patients underwent further testing with timed barium esophagography (TBE), standard barium esophagography, upper gastrointestinal endoscopy, high-resolution manometry (HRM). TBE measures height and width of a 250 cc oral bolus of barium at 1, 5 and 10 mins. At 5 mins., a 13 mm barium tablet is administered and passage of the tablet is noted. HRM measures several aspects of esophageal motor function, including lower esophageal sphincter (LES) relaxation, LES pressure, esophageal body peristaltic function, among others. The diagnosis of achalasia type (I, II or III) is based on HRM findings. Prior to surgical treatment, patients were given the Achalasia Symptom Questionnaire (ASQ) which is a validated instrument assessing the severity of achalasia symptoms (best score 10, worse score 31).
Results: 93 patients were included in this study. The mean ASQ score was 25.0+3.3. There was no statistically significant difference in scores among the achalasia types: I, 24.1+4.3; II, 25.6+2.8; and III, 24.9+4.2. Using linear regression analysis, there was no statistically significant correlation between ASQ scores and TBE column height or width at 1 and 5 mins. There was no statistically significant difference between patients who could pass a 13 mm barium tablet (23.4+5.0) and those who could not (25.3+3.1). There was no statistically significant correlation between LES pressure and peristalsis with ASQ scores.
Conclusion: Although physiological assessment of patients helps confirm the diagnosis of achalasia and the type, they do not correlate with patient perceived symptoms. Therefore the assessment of treatment outcomes of achalasia will need to require both an assessment of esophageal physiology and patient-centered symptoms and quality of life.
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