This article appeared originally In the April 2018 issue of the Penn GI News.
Clinician researchers at Penn Gastroenterology are investigating the complicated connection between obesity, nutritional risk and achalasia, a rare idiopathic motility disorder. The report of their study was published earlier this year (2018) in the journal Digestive Diseases and Sciences.
Although the etiology of achalasia remains unknown, its symptoms and treatment are relatively well understood. The disorder is brought about by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophagus, and is associated with a cascade of gastrointestinal effects that begins as dysphagia and concludes in chronic pain, weight loss and malnutrition.
The primary treatment is surgery or per oral endoscopic myotomy (POEM).
What remains ill-defined in achalasia is the relationship between the disorder and its ultimate bearing on weight loss and nutritional risk. Another unknown — the association between achalasia and obesity — remains an enigma, as well.
Achalasia is not uncommon in the obese, and can lead to a seemingly beneficial effect in this population, substantial and rapid weight loss. However, weight loss in the obese must be carefully managed and monitored to ensure appropriate nutrition. The absence of these controls in persons with obesity and achalasia presents a curious paradigm — malnutrition risk.
If weight loss is common in achalasia, little is known about patients' presenting weight class, degree of weight loss, associated nutritional risk, and response to treatment. To assess these factors, a retrospective cohort study was performed by a team of clinician researchers at Penn Gastroenterology. The study reviewed overweight and obese individuals presenting to Penn Medicine with documented achalasia as determined by symptom severity per Eckardt score (a clinical scoring tool for achalasia), and nutritional risk per the Malnutrition Universal Screening Tool, which considers BMI, degree of recent weight loss, and acuity of disease.
The aims of the study were to:
- evaluate the BMI and nutritional risk of patients presenting to a large tertiary referral center for management of achalasia,
- identify factors associated with nutritional complications, and
- evaluate the nutritional response to treatment.
Among the 337 patients presenting for achalasia management, 179 (53 percent) had confirmed disease and 69.8 percent were classified as overweight or obese (a proportion similar to that of the US population). Using the Malnutrition Universal Screening Tool (MUST), the researchers found 50 percent of patients to be at moderate or high risk for malnutrition at presentation.
Moreover, despite their elevated BMI status, one-third of overweight and obese achalasia patients were at moderate or high risk for nutritional complications by MUST score. Eckardt score, duration of disease, and female gender were independent predictors of increased risk for malnutrition. With treatment, nutrition risk score decreased in 93.3 percent of patients.
The authors hypothesized that malnutrition in the obese achalasia population was secondary to altered eating habits that lead to consumption of nutritionally depleted foods and recommended that all patients with achalasia undergo nutritional assessment regardless of baseline BMI to identify high-risk patients who may benefit from nutritional counseling, dietary intervention and expedited therapy.
Contributors to this research included Ravy K. Vajravelu, MD, MSCE; Octavia Pickett Blakely, MD, MS; Gary Falk, MD, MS; Yu Xiao Yang, MD, MSCE; and Kristle L. Lynch, MD.