Vigorous Achalasia

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Abstract
Vigorous achalasia was described in 1957 as a subset of achalasia with a higher contraction amplitude (>37 mm Hg), minimal esophageal dilatation, prominent tertiary contractions, and higher incidence of chest pain. Goals Ascertain the existence of a distinct achalasia group based on manometric, radiographic, and clinical grounds. Study The records of 209 idiopathic achalasia patients seen over a 9-year interval were reviewed for duration and frequency of dysphagia, chest pain, heartburn, weight loss, and nocturnal symptoms, as well as for treatment outcome. Manometric tracings were reanalyzed for lower esophageal sphincter pressure (LESP), LES residual pressure, distal esophageal contraction amplitude, and presence of repetitive waves. Patients were subsequently divided into classic (amplitude ≤37 mm Hg) and vigorous (amplitude >37 mm Hg) achalasia groups. Esophagrams were reassessed blindly for esophageal diameter both in the upright and recumbent positions and presence of lumen-occlusive tertiary contractions. Results One hundred forty-four classic and 65 vigorous achalasia patients were identified. These groups were similar in age and gender, as well as duration of symptoms. Chest pain was equally prevalent in both groups. Lower esophageal sphincter pressure was higher (p < 0.01) and repetitive waves more common (p < 0.0001) in the vigorous achalasia group. Upright esophageal diameter was smaller (p = 0.0003) and tertiary contractions more frequent (p = 0.0004) in this group. Conclusion The original manometric and radiographic description of vigorous achalasia is accurate. The incidence of chest pain is similar to that of patients with classic achalasia.