From the Guidelines
Chagas disease is a significant cause of achalasia, particularly in patients from endemic regions in Latin America, and diagnosis involves testing for T. cruzi antibodies in patients with achalasia 1.
Key Points to Consider
- Chagas disease, caused by the parasite Trypanosoma cruzi, can lead to achalasia as a long-term complication in some patients.
- Achalasia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the esophageal body.
- In Chagas disease, the parasite damages the enteric nervous system, particularly affecting the myenteric plexus, which controls esophageal motility.
- Diagnosis involves testing for T. cruzi antibodies in patients with achalasia, particularly those from endemic regions in Latin America.
- Treatment requires addressing both conditions: antiparasitic therapy for the Chagas infection, and management of achalasia through pneumatic dilation, peroral endoscopic myotomy (POEM), or surgical myotomy.
Management of Achalasia
- POEM, LHM, and PD are effective therapies for type I and type II achalasia; the decision among these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise 1.
- POEM should be considered the preferred treatment for type III achalasia.
- The presence of esophageal outflow obstruction at the EGJ and esophageal aperistalsis unifies the achalasia subtypes and directs interventional therapies to the lower esophageal sphincter (LES).
Importance of Early Diagnosis
- Early diagnosis of Chagas disease and achalasia is crucial to prevent long-term complications and improve treatment outcomes.
- Patients with epidemiological risk factors or other manifestations of Chagas disease such as cardiomyopathy should be considered for testing.
- A high index of suspicion is necessary to diagnose Chagas disease and achalasia, particularly in patients from endemic regions.
From the Research
Chagas Disease and Achalasia
- Chagas disease is a significant health concern in South America, and its esophagopathy (chagasic achalasia) has been extensively studied in Brazilian patients 2.
- The treatment options for achalasia in Chagas disease are similar to those for idiopathic achalasia, including diet and behavior changes, drugs, botulinum toxin, peroral endoscopic myotomy (POEM), pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, and esophagectomy 3.
- High-resolution manometry has been used to compare idiopathic achalasia and Chagas' disease esophagopathy, showing some differences in esophageal body pressures and lower esophageal sphincter basal and residual pressures 4.
Treatment Options
- Heller's myotomy is a common treatment for nonadvanced achalasia, while endoscopic treatment is reserved for limited cases 2.
- POEM is a modern and successful strategy for treating achalasia in Chagas disease, with good results in more than 90% of patients 3.
- Esophagectomy is an option for Chagas disease patients with advanced megaesophagus, despite the increased risk of complications 3.
Disease Management
- Chagas disease causes a life-threatening cardiopathy, which should be considered when choosing the most appropriate treatment for the disease 3.
- Benznidazole is one of the two therapeutic options available for Chagas disease, aiming to eliminate the parasite from the body and prevent the establishment or progression of visceral damage 5.
- The tolerance to nifurtimox and benznidazole in adult patients with chronic Chagas' disease has been compared, showing that currently recommended drug regimens are not well tolerated and entail frequent treatment discontinuation irrespective of the drug used 6.