Clinical characteristics and manometric findings of esophageal achalasia—a systematic review regarding differences among three subtypes

Esophageal achalasia is classified into three subtypes according to manometric findings. Since several factors, including clinical characteristics and treatment response, have been reported to differ among the subtypes, the underlying pathogenesis may also differ. However, a comprehensive understanding regarding the differences is still lacking. We therefore performed a systematic review of the differences among the three subtypes of achalasia to clarify the current level of comprehension. In terms of clinical features, type III, which is the least frequently diagnosed of the three subtypes, showed the oldest age and most severe symptoms, such as chest pain. In contrast, type I showed a higher prevalence of lung complications, and type II showed weight loss more frequently than the other types. Histopathologically, type I showed a high loss of ganglion cells in esophagus, and on a molecular basis, type III had elevated serum pro-inflammatory cytokine levels. In addition to peristalsis and the lower esophageal sphincter (LES) function, the upper esophageal sphincter (UES) function of achalasia has attracted attention, as an impaired UES function is associated with severe aspiration pneumonia, a fatal complication of achalasia. Previous studies have indicated that type II shows a higher UES pressure than the other subtypes, while an earlier decline in the UES function has been confirmed in type I. Differences in the treatment response are also crucial for managing achalasia patients. A number of studies have reported better responses in type II cases and less favorable responses in type III cases to pneumatic dilatation. These differences help shed light on the pathogenesis of achalasia and support its clinical management according to the subtype.