Transcription:
Considerations for the Management of Achalasia

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we examine personalized approaches to managing the treatment of achalasia. Joining me is Dr. Dustin Carlson. He's an Assistant Professor of Gastroenterology at Northwestern University Feinberg School of Medicine. Dr. Carlson, it's a pleasure to have you join us today. Tell us about some of the most important factors in the effective diagnosis and management of achalasia.

Dustin A. Carlson, MD, MSCI (Guest): First off, thank you so much for having me. I think when it comes to the important factors in effectively diagnosing and managing achalasia, that the starting point really is appropriately identifying patients that have achalasia. This sometimes can be a somewhat challenging disease to identify. And we certainly want to make sure that we're identifying it appropriately before we pursue some of the effective, though slightly invasive treatment options that can be very, very effective for this disorder.

Host: Why is it so difficult sometimes to diagnose? And why is accurate diagnosis and classification so important here?

Dr. Carlson: Yes, absolutely. And as I mentioned, there, there are these effective treatment options for achalasia and they carry a really high rate of symptom improvement. And we use the most minimally invasive options available. However, these options all do disrupt the muscle of the esophagus, predominantly the lower esophageal sphincter. And so while the treatment is essential to improve these achalasia symptoms, if we were to do that in someone who didn't have achalasia, it obviously would not improve the symptoms. And it could also lead to some clinical consequences, as a result of the treatment. When we diagnose achalasia, we sometimes have to use a variety of diagnostic options to both identify and classify achalasia.

This starts with excluding other potentially alternative diagnoses that can mimic achalasia type symptoms. We use endoscopy to do that primarily. And then a combination of other tests with esophageal manometry, barium esophogram and even then, the functional luminal imaging probe or FLIP device, which all help us accurately identify and characterize achalasia.

Host: So, then tell us about some of the leading evidence-based treatments for it. And how is Northwestern's team determining this right treatment fit? Tell us about the process.

Dr. Carlson: So, there are a few different effective treatment options for achalasia. And those include a pneumatic dilation which is an endoscopically performed, large caliber balloon dilation of the lower esophageal sphincter. There's also the Heller myotomy, which is a laparoscopic surgery that cuts the lower esophageal sphincter with surgical precision. And finally there's a procedure called the POEM, which stands for peroral endoscopic myotomy, which is a, an endoscopic surgery hybrid. So, it's performed with endoscopy but is a little bit more minimally invasive and allows cutting of the lower esophageal sphincter with surgical precision.

And so, when we see a patient at Northwestern, obviously that first step is to confirm that achalasia is the correct diagnosis. But next we attempt to actually subtype and further characterize the achalasia specifically and this allows us to personalize a specific treatment approach that will carry the highest likelihood for success for that patient. And so we do this by reviewing the collective test data that includes the endoscopy, the manometry, the FLIP, the esophogram. So, bringing it all together and certain things that we look for one is that if the findings support that it's a spastic subtype of achalasia, the spasm, we recognize is something that's going to carry a highest potential for success if we treat with surgical myotomy, particularly the POEM procedure. Additionally, there may be some other anatomic factors such as the shape of the esophagus that may direct us toward one treatment option for another. And so ultimately, by taking this kind of an overall comprehensive evaluation of a patient's achalasia and a patient's esophagus, we can hope to find that the best treatment.

However, there are some scenarios where we can determine that there's multiple treatment options that are going to be equally effective. And then we may offer the multiple treatment options to the patient. And each of these treatment options do have some inherent pros and cons, related to recovery time or durability of treatment of X. And so, in those scenarios, we can come to discuss those with the patients and actually share the decision with the patient, and really direct towards the patient preferences on how we pursue the treatment options.

Host: Well, that certainly is a personalized approach. And you have a paper in the American Journal of Gastroenterology that identified repeated diagnostics as an important step in diagnosis. Tell us more about the significance of that and tell us about your paper.

Dr. Carlson: So, with all these treatment options in achalasia that we know that they're very likely to improve achalasia symptoms up front, but the treatments are not curative. They all address, one of the abnormalities, this obstruction at the lower esophageal sphincter. But we can sometimes see that patients with achalasia can actually go into a bit of a honeymoon period, where that can occur when patients are feeling really well. And their symptoms may be pretty mild or even nonexistent. But it's during that time that the esophagus can actually remodel, which means that the esophagus can actually become dilated and sometimes even would start to become kind of torturous or kind of twist and turn. When that remodeling occurs, it can make future treatment option little more limited and potentially even less effective. And so in some way, the repeated diagnostics and the surveillance of achalasia over time, hopefully allows us to detect some of those changes, earlier and prevent that remodeling process that can occur.

Host: Is there a multidisciplinary approach that you use to help with this personalized medicine? Tell us about who else works with you and how you all work together for these patients. Why it's so important that they get this multidisciplinary team.

Dr. Carlson: As I mentioned, there's the multiple treatment options. Some of those being surgical, some of those being endoscopic and so I, myself as a Gastroenterologist perform the pneumatic dilation. Some of my surgical colleagues and some of my advanced endoscopy colleagues perform the Heller myotomy and the POEM procedure.

And so often it does take the combined approach between myself and another minimally invasive surgeon to discuss the treatment options. But additionally, there is that shared management in identifying these patients, and also following them over time. And sometimes even beyond just the endoscopic or surgical treatments, we do recognize that there's other factors that can be involved in symptoms. So, we have a great focused dietician that is sometimes involved. And so we're kind of using this full team together that can allow us to really accurately identify and treat achalasia.

Host: Is Northwestern involved in any research evaluating treatments for achalasia?

Dr. Carlson: So, Northwestern is very active in research. And achalasia is definitely one of the disorders that we focus our research on. So, we have numerous research protocols in place, and each of these are really trying to place the improve some of the areas that need improvement. So, in trying to improve identification of achalasia, trying to improve some of this tailoring of a personalized, specific treatment approach, and also to try to identify factors that may be involved in the progression of achalasia. So, some of this remodeling and seeking other ways to potentially prevent it.

Host: What do you think the next steps are to advance diagnosis and treatment of achalasia and anything else you'd like to include about the identification or treatment and management of this condition for other providers? Kind of give us a summary of what you think are the most important points about what you do.

Dr. Carlson: So, I think there's been some really tremendous advances in the identification of achalasia with new technologies over the last decade or so. With high-resolution manometry, there's achalasia subtypes, and there's some developments, even POEM is a relatively new treatment option that's been effective and minimally invasive for treating achalasia. But I think as these kind of new advances come out, we're learning more and more from those. And so there's areas that they sometimes have highlighted that we're trying to continue to improve upon. Additionally, we are started to see more and more now some of these patients that probably do have achalasia, but their diagnostics don't fit into the classic patterns and criteria as perfectly as we were originally potentially thought to believe. And so I guess we call these sometimes achalasia variants, for lack of a better term.

But these can be clinically challenging. And this is the scenario, where it often does take that kind of multifaceted approach to effectively identify who these patients are, and find the best ways to, to treat them. Additionally, some of this achalasia, these processes that result in remodeling, and even coming back to the root cause of achalasia. These are factors that remain relatively uncertain as to what causes them. So some of our efforts are looking into these other processes that we can identify specific causes or factors. These may be things that could potentially be addressed and reversed to avoid that remodeling and the process of progression.

Host: And what would you like other physicians to know about referral and the importance of early referral to the specialists at Northwestern Medicine?

Dr. Carlson: I think one thing with achalasia that continues to surprise me, even after years of doing this, is how long patients often will go kind of just managing with symptoms. They often are initially diagnosed as having or at least suspected to have gastroesophageal reflux disease and maybe treated for GERD for years as symptoms kind of slowly progress.

So, I think just recognizing that achalasia is a disorder that has effective treatment options and that effective treatment options, are more effective if they're pursued early. And so, when patients are maybe having suspected for GERD, but not responding to the initial treatment, evaluation for other causes really should be pursued. And at Northwestern, we do have, as we mentioned, a multi disciplinary team to help accurately identify and potentially treat patients in a very, very effective manner going forward.

Host: Thank you so much, Dr. Carlson for joining us and sharing your expertise with us today. To refer your patient, please visit our website@nm.org to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. This is Melanie Cole.