Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub‐group

Background Type II achalasia (Ach2) is distinguished from other achalasia sub‐types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high‐resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub‐groups of Ach2. Methods This retrospective single center study performed over 3 years (1/2019–1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub‐groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub‐groups utilizing unpaired univariate analyses. Key Results Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub‐group without FEPs, the Ach2 sub‐group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2/mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). Conclusions and Inferences We identified a distinct sub‐group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub‐group uniquely exhibits spastic features and may benefit from personalized treatment approaches. Type II achalasia with focal elevated pressures (FEPs)—focal or segmental areas of pressurization ≥70 mmHg within the panesophageal pressure band—represent a distinct sub‐group of type II achalasia on high resolution manometry. This sub‐group uniquely exhibits spastic features and may benefit from personalized treatment approaches.