Joseph Triggs

Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity

Achalasia is a disease of mechanical esophageal dysfunction characterized by dysphagia, chest pain, regurgitation, and malnutrition. The Eckardt symptom score (ESS) is the gold standard self‐report assessment tool. Current guidelines outline a three‐step approach to patient reported outcomes measure design. Developed prior to these policies, the ESS has not undergone rigorous testing of its reliability and validity.

Validation of the oesophageal hypervigilance and anxiety scale for chronic oesophageal disease

Oesophageal hypervigilance and anxiety can drive symptom experience in chronic oesophageal conditions, including gastro‐oesophageal reflux disease, achalasia and functional oesophageal disorders. To date, no validated self‐report measure exists to evaluate oesophageal hypervigilance and anxiety.

Editorial: Assessing Esophageal Function in Achalasia: The Old and the New

Abstract: Achalasia is currently diagnosed according to the Chicago Classification v3.0 using high-resolution manometry and treatment focuses on disruption of the esophagogastric junction. A paper in this issue examines the utility of a timed barium esophagram with a 13 mm tablet challenge in differentiating achalasia from other diagnoses, finding 100% sensitivity. However, a large proportion of patients with non-achalasia dysphagia are also identified. Another paper in this issue proposes utilizing intraprocedure functional luminal imaging probe measurement during pneumatic dilation as a guide for upsizing dilations. This appears promising, but prospective validation is necessary before this becomes standard of care.

Editorial: symptom association probability during reflux testing—what is the gain?

Reflux monitoring is indicated for patients with suspected refractory reflux symptoms, but without convincing oesophagitis on endoscopy. Significantly abnormal acid exposure (ie > 6%) equates to a diagnosis of gastro-oesophageal reflux disease (GERD). However that begs the question of whether or not the refractory symptoms are reflux-related. The symptom index (SI) and symptom association probability (SAP) were developed to address that question. Notably, these measures were developed for pH-metry without impedance monitoring and for the typical reflux symptoms of heartburn, chest pain and regurgitation. Subsequently they have been co-opted to use with impedance monitoring, atypical symptoms, and to distinguish reflux hypersensitivity from functional heartburn. In a recent issue of the journal, Choksi et al questioned the validity of this expanded usage, especially if used as an indication for anti-reflux surgery. Choksi et al analysed SAP data in a retrospective series of 205 patients who underwent 48-hour wireless pH testing (off PPI) with refractory ‘GERD’ symptoms divided into groups with and without oesophagitis and with or without abnormal acid exposure times. Their central argument throughout is that a positive or negative SAP was an unreliable means for guiding management in any of these patient subsets based on several limitations and observations: (1) 18% of patients had discordant SAP values between days 1 and 2 of pH-metry, (2) the SAP outcome was extraordinarily dependent on accurate symptom reporting by the patient during pH-metry and all indications are that this is the exception rather than the rule, (3) the fewer the number of symptoms reported, the less reliable the SAP becomes and (4) in a sub-analysis of 58 patients who underwent fundoplication, a favourable outcome was equally likely (or unlikely in the case of atypical symptoms) in those that were SAP-positive or -negative. These are potent arguments that, despite the conceptual validity of reflux-symptom correlation, it is deeply flawed as commonly practised. So, what is the clinical gain from the SAP determination? When carefully done in patients with typical reflux symptoms, the SAP can no doubt predict response to medical therapy; but so does an empirical trial of medical therapy. Similarly, when sufficient symptom episodes are compulsively reported in the course of the study, the SAP distinguishes reflux hypersensitivity from functional heartburn. However, this distinction has little clinical implication as the treatments for both entities centre on cognitive behavioural therapy and neuromodulation. More important is what the SAP has not been shown to do and what it should not be used for; to predict response to anti-reflux surgery for medically refractory symptoms. Unfortunately, that would be its most useful clinical application.