Epidemiology and Practice Patterns of Achalasia
Epidemiology and Practice Patterns of Achalasia
Background Due to its rarity, achalasia remains a difficult disease to study.
Aims To describe the epidemiology of achalasia and practice patterns in its endoscopic management, utilising patient records from a large national database of endoscopic procedures.
Methods The Clinical Outcomes Research Initiative maintains a database of endoscopic procedures in diverse clinical practices. The data from 89 endoscopy practices distributed throughout the US during 2000–2008 were used to analyse the characteristics and therapy of patients with achalasia.
Results Among 521 497 upper endoscopies during the study period, we identified 896 patients with achalasia. Compared with the entirety of all other endoscopic diagnoses, achalasia was more common in men than in women (OR = 1.39, CI 1.22–1.59), but similar among nonwhites and whites (OR = 0.87, CI 0.74–1.03). Relatively, more achalasia patients were treated at university than at community practices (OR = 1.52, CI 1.30–1.78). Botox injection was most frequently used as first choice of endoscopic therapy in 41%, followed by balloon dilation in 21%, Savary dilation in 20%, Maloney dilation in 10%, Rigiflex in 4% and other modalities in 4% of patients. One quarter of achalasia patients treated endoscopically underwent a repeat therapy about every 14 months.
Conclusions Botox has become the primary choice of initial endoscopic therapy in achalasia. Despite their partial deviation from guidelines and recommendations, these endoscopic patterns reflect the current clinical practice in the United States.
Achalasia is a primary oesophageal motility disorder of unknown aetiology. It is characterised by failure of the lower oesophageal sphincter to relax and abnormal peristalsis of the oesophageal body during swallowing. Despite its recognition as a clinical entity for several centuries, it has remained one of the least understood gastroenterological diseases, at least in part due to its low prevalence of approximately 0.01%. Although several suggestions have been made on its underlying aetiology, such as exposure to noxious environmental influences, infection, genetic abnormality or autoimmune disease, none of these theories have survived rigorous study or gained general acceptance. Epidemiological studies could serve as means to identify potential risk factors that play a role in the development of this rare disease. Large centres dedicated to the research of achalasia have followed fewer than 300 patients. Most clinical studies of achalasia have struggled in providing reliable epidemiologic data, as they were rarely able to recruit more than 50–100 patients into a single study. Similarly, given these relatively small patient groups from individual tertiary care centres, the current practice patterns in the general management of achalasia have not been previously described in a representative population of achalasia patients.
The Clinical Outcomes Research Initiative database (CORI) is a national multi-centre consortium of gastroenterology practices distributed throughout the United States. CORI includes community, Department of Veterans Affairs (VA) and academic practices. The CORI database is uniquely suited for the study of achalasia because of its large and geographically varied sample size. The aims of the present study were to utilise the CORI database to describe the demographic characteristics and practice patterns in the endoscopic management of patients with achalasia between 2000 and 2008.
Abstract and Introduction
Abstract
Background Due to its rarity, achalasia remains a difficult disease to study.
Aims To describe the epidemiology of achalasia and practice patterns in its endoscopic management, utilising patient records from a large national database of endoscopic procedures.
Methods The Clinical Outcomes Research Initiative maintains a database of endoscopic procedures in diverse clinical practices. The data from 89 endoscopy practices distributed throughout the US during 2000–2008 were used to analyse the characteristics and therapy of patients with achalasia.
Results Among 521 497 upper endoscopies during the study period, we identified 896 patients with achalasia. Compared with the entirety of all other endoscopic diagnoses, achalasia was more common in men than in women (OR = 1.39, CI 1.22–1.59), but similar among nonwhites and whites (OR = 0.87, CI 0.74–1.03). Relatively, more achalasia patients were treated at university than at community practices (OR = 1.52, CI 1.30–1.78). Botox injection was most frequently used as first choice of endoscopic therapy in 41%, followed by balloon dilation in 21%, Savary dilation in 20%, Maloney dilation in 10%, Rigiflex in 4% and other modalities in 4% of patients. One quarter of achalasia patients treated endoscopically underwent a repeat therapy about every 14 months.
Conclusions Botox has become the primary choice of initial endoscopic therapy in achalasia. Despite their partial deviation from guidelines and recommendations, these endoscopic patterns reflect the current clinical practice in the United States.
Introduction
Achalasia is a primary oesophageal motility disorder of unknown aetiology. It is characterised by failure of the lower oesophageal sphincter to relax and abnormal peristalsis of the oesophageal body during swallowing. Despite its recognition as a clinical entity for several centuries, it has remained one of the least understood gastroenterological diseases, at least in part due to its low prevalence of approximately 0.01%. Although several suggestions have been made on its underlying aetiology, such as exposure to noxious environmental influences, infection, genetic abnormality or autoimmune disease, none of these theories have survived rigorous study or gained general acceptance. Epidemiological studies could serve as means to identify potential risk factors that play a role in the development of this rare disease. Large centres dedicated to the research of achalasia have followed fewer than 300 patients. Most clinical studies of achalasia have struggled in providing reliable epidemiologic data, as they were rarely able to recruit more than 50–100 patients into a single study. Similarly, given these relatively small patient groups from individual tertiary care centres, the current practice patterns in the general management of achalasia have not been previously described in a representative population of achalasia patients.
The Clinical Outcomes Research Initiative database (CORI) is a national multi-centre consortium of gastroenterology practices distributed throughout the United States. CORI includes community, Department of Veterans Affairs (VA) and academic practices. The CORI database is uniquely suited for the study of achalasia because of its large and geographically varied sample size. The aims of the present study were to utilise the CORI database to describe the demographic characteristics and practice patterns in the endoscopic management of patients with achalasia between 2000 and 2008.
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