Epidemiology and practice patterns of achalasia in a large multi-centre database

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.