O papel da endoscopia no diagnóstico e tratamento de Acalasia

Rebeca Silva Moreira da Fraga; José Joaquim de Almeida Figueiredo; Thaisa de Moraes Ribeiro Espírito Santo; Esteban Sadovsky

doi:10.47456/rbps.v26isupl_3.15

Authors

Rebeca Silva Moreira da Fraga Hospital Universitário Cassiano Antônio Moraes
José Joaquim de Almeida Figueiredo Hospital Universitário Cassiano Antônio Moraes
Thaisa de Moraes Ribeiro Espírito Santo Hospital Universitário Cassiano Antônio Moraes
Esteban Sadovsky Hospital Universitário Cassiano Antônio Moraes

DOI:

https://doi.org/10.47456/rbps.v26isupl_3.15

Keywords:

Achalasia, Upper gastrointestinal endoscopy, Esophageal motor disorder, Endoscopy

Abstract

Introduction: Achalasia is a rare disease, whose main symptoms are dysphagia, regurgitation and weight loss, but may be nonspecific in the early stages. The diagnosis is defined by esophageal manometry, however, due to its low availability, endoscopy plays an important role in the identification and especially in the treatment of this disease. Objectives: To describe the role of endoscopy in the diagnosis, given the difficulty in accessing manometry, and also in the treatment of achalasia. The endoscopic findings, procedures currently performed and when to use them were highlighted. Methods: Review of the medical literature of articles selected from PubMed. Results: If achalasia is suspected, endoscopy is the first test to be performed to rule out other diseases such as pseudoachalasia and strictures. Furthermore, endoscopic findings can contribute to suspicion of the disease, anticipating a diagnosis that is often late. Regarding treatment, POEM is currently the therapy of choice, especially in type III achalasia, and achieves symptom control in more than 93% of cases. Heller myotomy surgery presents results close to POEM, and even though it is more invasive, it may be the best option in specialized centers. Although less durable, balloon dilation is effective and is often the first choice due to the best cost-benefit and accessibility. Conclusion: Achalasia is a difficult disease to diagnose and a detailed endoscopic evaluation can help identify it early, especially when manometry is unavailable. Treatment must be individualized and currently the best therapies are POEM, followed by surgery, as both present similar and lasting results. Balloon dilation is also effective, with good results, and can often be the first choice for the best cost-benefit.

Downloads

References

1. Riccio F, Costantini M, Salvador R. Esophageal Achalasia: Diagnostic Evaluation. World Journal of Surgery. 2022 Feb 23;

2. Iwakiri K, Hoshihara Y, Kawami N, Sano H, Tanaka Y, Umezawa M, et al. The appearance of rosette-like esophageal folds (“esophageal rosette”) in the lower esophagus after a deep inspiration is a characteristic endoscopic finding of primary achalasia. Journal of Gastroenterology. 2009 Dec 16;45(4):422–5.

3. Han SO, Youn YH. Role of endoscopy in patients with achalasia. Clinical Endoscopy. 2023 Jun 2;

4. Moonen A, Boeckxstaens G. Current Diagnosis and Management of Achalasia. Journal of Clinical Gastroenterology. 2014 Jul;48(6):484–90.

5. Minami H, Isomoto H, Miuma S, Kobayashi Y, Yamaguchi N, Urabe S, et al. New Endoscopic Indicator of Esophageal Achalasia: “Pinstripe Pattern.” PLoS ONE [Internet]. 2015 Feb 9;10(2):e0101833.

6. Riccio F, Costantini M, Salvador R. Esophageal Achalasia: Diagnostic Evaluation. World Journal of Surgery. 2022 Feb 23;

7. Spechler SJ, Souza RF, Rosenberg SJ, Ruben RA, Goyal RK. Heartburn in patients with achalasia. Gut. 1995 Sep 1;37(3):305–8.

8. Iwakiri K, Hoshihara Y, Kawami N, Sano H, Tanaka Y, Umezawa M, et al. The appearance of rosette-like esophageal folds (“esophageal rosette”) in the lower esophagus after a deep inspiration is a characteristic endoscopic finding of primary achalasia. Journal of Gastroenterology. 2009 Dec 16;45(4):422–5.

9. Pratap N, Kalapala R, Darisetty S, Joshi N, Ramchandani M, Banerjee R, et al. Achalasia Cardia Subtyping by High-Resolution Manometry Predicts the Therapeutic Outcome of Pneumatic Balloon Dilatation. Journal of Neurogastroenterology and Motility. 2011 Jan 31;17(1):48–53.

10. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010 Mar 30;42(04):265–71.

11. Conrado ACC. Tratamento endoscópico na Acalásia de Esôfago. In: Averbach M, editor. Tratado ilustrado de Endoscopia Digestiva da SOBED. Rio de Janeiro: Thieme Revinter; 2018. p. 763-766.

12. Schlottmann F, Luckett DJ, Fine J, Shaheen NJ, Patti MG. Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia. Annals of Surgery. 2017 Mar;267(3):451–60.

13. Ramalho CO, Conrado AC et al. – Miotomia endoscópica (ME) para tratamento de acalasia – atualização de dados – relato de 200 casos, Centro de Treinamento XIV. Sem Brasi Ap Digest 2015.

14. Schlottmann F, Patti MG. Esophageal achalasia: current diagnosis and treatment. Expert Review of Gastroenterology & Hepatology. 2018 Jun 8;12(7):711–21.

15. Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. American Journal of Gastroenterology. 2020 Aug 10;115(9):1393–411.

16. Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. The New England Journal of Medicine [Internet]. 2011 May 12;364(19):1807–16.

17. Conrado ACC. Tratamento endoscópico na Acalásia de Esôfago. In: Averbach M, editor. Tratado ilustrado de Endoscopia Digestiva da SOBED. Rio de Janeiro: Thieme Revinter; 2018. p. 763-766.

18. West RL, Hirsch DP, Bartelsman JF, J de Borst, Ferwerda G, G. N. J. Tytgat, et al. Long term results of pneumatic dilation in achalasia followed for more than 5 years. 2002 Jun 1;97(6):1346–51.

19. Sudarshan M, Raja S, Adhikari S, Murthy S, Thota P, Gabbard S, et al. Peroral endoscopic myotomy provides effective palliation in type III achalasia. The Journal of Thoracic and Cardiovascular Surgery. 2022 Feb;163(2):512-519.e1.

20. Pasricha PJ. Treatment of Achalasia with Intrasphincteric Injection of Botulinum Toxin: A Pilot Trial. Annals of Internal Medicine. 1994 Oct 15;121(8):590.

21. Pasricha P, Rai R, Ravich W, Hendrix T, Kalloo A. Botulinum toxin for achalasia: Long-term outcome and predictors of response. Gastroenterology. 1996 May;110(5):1410–5.

22. Yamaguchi D, Tsuruoka N, Sakata Y, Shimoda R, Fujimoto K, Iwakiri R. Safety and efficacy of botulinum toxin injection therapy for esophageal achalasia in Japan. Journal of Clinical Biochemistry and Nutrition. 2015;57(3):239–43.