A Novel Endoscopic Finding of Achalasia: "Endoscopic Vertebrae Sign"

Achalasia is an esophageal motility disorder that significantly impairs quality of life. Recently, peroral endoscopic myotomy has yielded satisfactory treatment outcomes. Although the current gold standard is esophageal high-resolution manometry (HRM), early endoscopic detection is essential for accurate diagnosis. Dilatation of the esophageal lumen during endoscopy is subjective and has not been fully evaluated. We focused on the extramural compression of the vertebrae in the esophagus, which may reflect dilatation of the esophageal lumen, named the endoscopic vertebrae sign (EVS), and examined the possibility of the EVS as a novel endoscopic finding of achalasia.

Forty-three patients were diagnosed with achalasia using HRM between July 2013 and November 2022. Five who underwent surgical treatment and one for whom esophagogram was unavailable were excluded, resulting in 37 patients in the achalasia group. Among those who underwent comprehensive medical checkups and esophagogastroduodenoscopy screening at our hospital during the same period, all age- and sex-matched individuals were randomly extracted and 74 were set as controls. The rates of EVS, endoscopic esophageal dilatation at the endoscopist's discretion, and number of visible vertebrae in a single endoscopic view were retrospectively analyzed.

In the achalasia group, the proportion with EVS was 86.5%, with endoscopic esophageal dilatation at the endoscopist's discretion 76%, and the number of visible vertebrae in patients with EVS was 3.2 ± 0.9. These findings differed significantly in controls: 9.5%, 0%, and 1.4 ± 0.4, respectively (p < 0.001).

EVS may be one of the endoscopic findings associated with esophageal dilatation and suggestive of achalasia.