PTH-133 Achalasia despite normal integrated relaxation pressure with 5ml water swallows. (17th June 2017) - Sanagapalli, S
Abstract : Introduction: Resistance to bolus flow across the lower esophageal sphincter (LES) is a hallmark of achalasia. Presently the gold standard of diagnosis is by high-resolution manometry (HRM) demonstration of raised integrated relaxation pressure (IRP) following ten 5 mL water swallows; however, this does not replicate normal swallowing behaviour. It has been demonstrated that the addition of adjunctive tests improves sensitivity of identifying relevant dysmotility. Such tests include multiple water swallows (MWS; 200 mL water drunk freely) and solid swallows. In addition, the timed barium esophagram (TBE) measures esophageal emptying. This study describes a cohort of patients who have been treated as having achalasia based on resistance to flow not exhibited with single water swallows. Method: Inclusion criteria were all patients between October 2014–2016 with normal mean and median IRP with 5 mL water swallows but considered to have achalasia due to resistance to flow demonstrated by pan-esophageal pressurisation (PEP) during MWS or solid swallows and/or a persistent column at 5 min during TBE. Outcome post-treatment was based on Eckardt score (ES). Results: 14 patients (9 male) fulfilled inclusion criteria. 7 were treatment-naïve and 7 treatment-experienced (3 myotomy, 4 dilatation). Mean resting LES pressure was 14.6±7.4 mmHg. In all patients, mean and median IRP values for ten 5 mL water swallows were non-raised (mean 9.1±4.3 and 8.7±4.5 mmHg respectively). Of the 7 treatment-naïve patients, 5 demonstrated PEP on MWS, 3 on solid swallows and 6 had a positive TBE at 5 min. In treatment-experienced patients, 5 had PEP on MWS, 1 on solid swallows and all had a positive TBE. Of the 13 who had resistance to flow on TBE, 10 (77%) also had resistance demonstrated during MWS and/or solid swallows. Mean height of the 5 min column of barium at baseline was 16.5±8.9 cm. 8 patients underwent therapy based on these findings; one POEM and 7 pneumatic dilatations. Median baseline ES was 7.5 (IQR 5–8). Median ES at minimum 3 months following treatment was 1 (IQR 0–2.5; p<0.01 cf. baseline). Similarly, there was significant improvement in TBE findings post-therapy (mean 5 min column height 3.5±4.1 cm; p=0.04 cf. baseline). Conclusion: A normal IRP for water swallows does not preclude a diagnosis of achalasia. The addition of free drinking/solids during HRM or the TBE can identify pathology that might have been missed with standard 5 mL water swallows alone. Patients treated based on this algorithm exhibit excellent treatment outcomes, validating this approach. Disclosure of Interest: None Declared