Revista de Gastroenterología de México Revista de Gastroenterología de México
Rev Gastroenterol Mex 2018;83:1-2 - Vol. 83 Num.1 DOI: 10.1016/j.rgmxen.2017.12.001
Editorial
Achalasia subtype differences based on clinical symptoms, radiographic findings, and stasis scores
Diferencias en los subtipos de acalasia basadas en síntomas clínicos, hallazgos radiológicos y puntajes de estasis
M.A. Valdovinos Díaz,
Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

The article by Meillier et al.1 included in this issue evaluated the clinical differences between achalasia subtypes based on symptoms, esophagram, and a new esophageal stasis score measured with high-resolution impedance manometry (HRIM). The findings of interest in that study on 108 patients are: 1) clinical symptoms did not aid in distinguishing the different achalasia subtypes, with the exception of vomiting, which was more common in subtype I; 2) the degree of esophageal dilation, obtained through measuring the largest diameter of the distal esophagus in the esophagram, was significantly less in subtype III, but no difference was found in subtypes I and II, and 3) the stasis scores of the three subtypes showed no differences.

Despite the limitations inherent in the retrospective design of the study and the small number of patients with subtype I, it demonstrated the impossibility of classifying achalasia subtypes through symptom questionnaires or parameters of esophageal stasis measurement. High resolution manometry is essential for establishing achalasia classification, whose prediction of treatment response results in its well-known prognostic importance.2–7

A striking aspect of the case series by Meillier et al.1 was the lower mean age of patients with subtype I, compared with those with subtypes II and III. Even more intriguing was the fact that the esophageal diameter was greater in subtype II achalasia than in subtype I. Previous studies led us to infer that subtype II corresponded to initial stages of achalasia and that subtype I occurred in advanced disease stages, with the characteristic important dilation of the esophageal body and retention of food remnants.8 The findings by Meillier et al.1 do not concur with that hypothesis. In addition, studies that evaluated the histologic alterations and the type of inflammatory infiltrate of the lower esophageal sphincter obtained through biopsy of complete muscle thickness during surgical myotomy have posited that type III achalasia appears to behave differently from types I and II, suggesting a different pathophysiologic mechanism in terms of neuromuscular lesion.9 Further studies are needed to clarify our knowledge of the natural history of achalasia and the factors that determine its different manometric types.

Financial disclosure

No financial support was received in relation to this article.

Conflict of interest

The author declares that there is no conflict of interest.

References
1
Meillier A, Midani D, Caroline D, et al. Difference of achalasia subtypes based on clinical symptoms, radiographic findings, and stasis scores [Article in English, Spanish]. Rev Gastroenterol Mex. 2017.
2
J. Furuzawa-Carballeda,D. Aguilar-Leon,A. Gamboa-Dominguez
Achalasia--An Autoimmune Inflammatory Disease: A Cross-Sectional Study
J Immunol Res, 2015 (2015), pp. 729217 http://dx.doi.org/10.1155/2015/729217
3
V. Villanacci,V. Annese,A. Cuttitta
An Immunohistochemical Study of the Myenteric Plexus in Idiopathic Achalasia
J Clin Gastroenterol, 44 (2010), pp. 407-410 http://dx.doi.org/10.1097/MCG.0b013e3181bc9ebf
4
S.B. Clark,T.W. Rice,R.R. Tubbs
The Nature of the Myenteric Infiltrate in Achalasia
Am J Surg Pathol, 24 (2000), pp. 1153-1158
5
P.L. Moses,L.M. Ellis,M.R. Anees
Antineuronal antibodies in idiopathic achalasia and gastro oesophageal reflux disease
Gut, 52 (2003), pp. 629-636
6
A. Ruiz-De-Leon,J. Mendoza,C.N. Sevilla-Mantilla
Myenteric antiplexus antibodies and class II HLA in achalasia
Digest Dis Sci, 47 (2002), pp. 15-19
7
J.E. Pandolfino,M.A. Kwiatek,T. Nealis
Achalasia: A new clinically relevant classification by high-resolution manometry
Gastroenterology, 135 (2008), pp. 1526-1533 http://dx.doi.org/10.1053/j.gastro.2008.07.022
8
J.Y. Lee,N. Kim,S.E. Kim
Clinical characteristics and treatment outcomes of 3 subtypes of achalasia according to the chicago classification in a tertiary institute in Korea
J Neurogastroenterol Motil, 19 (2013), pp. 485-494 http://dx.doi.org/10.5056/jnm.2013.19.4.485
9
J. Furuzawa-Carballeda,D. Aguilar-León,A. Gamboa-Domínguez
Achalasia--An Autoimmune Inflammatory Disease: A Cross-Sectional Study
J Immunol Res, 2015 (2015), pp. 729217 http://dx.doi.org/10.1155/2015/729217

Please cite this article as: Valdovinos Díaz M. Diferencias en los subtipos de acalasia basadas en síntomas clínicos, hallazgos radiológicos y puntajes de estasis. Revista de Gastroenterología de México. 2018;83:1–2.

Puente de Piedra 150-617, Col. Toriello Guerra, C.P. 14050, Mexico City, Mexico. Tel.: ++525556067987. (M.A. Valdovinos Díaz miguelvaldovinosd@gmail.com)
Rev Gastroenterol Mex 2018;83:1-2 - Vol. 83 Num.1 DOI: 10.1016/j.rgmxen.2017.12.001