Increased esophageal hypervigilance and anxiety were associated with worse post-treatment symptoms and poor quality of life in patients with achalasia, a rare esophageal motility disorder, according to a recent Northwestern Medicine study.
The findings, published in Gastroenterology, demonstrate how psychological processes are associated with physiological processes that occur alongside poor treatment outcomes.
Achalasia is a rare swallowing disorder in which damaged nerves in the esophagus prevent food and liquid from moving through the esophagus to the stomach. Symptoms can include food impaction, difficulty swallowing, or dysphagia, and chest pain.
While there is no cure, endoscopic and surgical treatments can help patients manage their symptoms. However, a subset of patients will continue to experience symptoms and poor quality of life despite treatment. Previous work suggests that esophageal hypervigilance — having a heightened focus on sensations in the esophagus — and anxiety caused by symptoms may be associated with symptom severity and quality of life in patients with achalasia.
“Esophageal hypervigilance is when you focus attention on the esophagus in response to a perceived threat, so you anticipate pain is going to come or you anticipate something is going to be harmful in your esophagus. Esophageal-specific anxiety is the worry of esophageal symptoms, as well as their perceived consequences,” said Livia Guadagnoli, ‘20 PhD, research assistant professor of Medicine in the Division of Gastroenterology and Hepatology and lead author of the study.
In the current study, Guadagnoli and colleagues aimed to determine the role of esophageal hypervigilance and anxiety in predicting post-treatment symptom severity and quality of life by analyzing a dataset involving in more than 90 patients who received treatment for achalasia.
Patients were an average age of 55 years and were treated for achalasia with pneumatic dilation, per-oral endoscopic myotomy, or laparoscopic Heller myotomy at the Northwestern Medicine Kenneth C. Griffin Esophageal Center between 2015 and 2023.
All patients underwent pretreatment timed barium esophagram (TBE) — an x-ray test that measures how quickly liquid empties from the esophagus into the stomach — and high-resolution manometry, which uses a catheter to measure pressure changes in the esophagus. Patients also completed questionnaires before and after treatment regarding symptom severity, esophageal hypervigilance and anxiety, and quality of life using the Eckardt Symptom Score, the Esophageal Hypervigilance and Anxiety Scale and the and Northwestern Esophageal Quality of Life Scale.
Using multiple data analysis techniques, the investigators found that higher baseline esophageal hypervigilance and anxiety scores predicted higher post-treatment symptom severity and lower quality of life. Interestingly, they also found that worse esophageal function at baseline was associated with higher quality of life post-treatment.
“Our hypothesis was that if someone has a really dysfunctional esophagus and they get treatment, they’re probably going to experience at least some improvement that’s going to improve quality of life,” Guadagnoli said.
These findings prompted the investigators to perform an additional data analysis, which found that esophageal hypervigilance and anxiety significantly affect the relationship between TBE height and quality of life. Notably, among patients with high esophageal hypervigilance and anxiety, those with poor esophageal function at baseline had better post-treatment quality of life scores. In contrast, those with better baseline esophageal function had worse post-treatment quality-of-life scores.
“If you have a high TBE column height, you’re retaining fluid, you’re retaining food and your esophagus is really not working well, so of course you’re going to be hypervigilant and anxious. You go and get treatment and then esophageal function improves, hypervigilance and anxiety likely decreases, and your quality of life improves. But if you’re highly vigilant and anxious and there’s not a lot of esophageal dysfunction, then the treatment’s probably not going to be as effective and you’re going to continue to experience hypervigilance and anxiety, which can contribute to a poor and impacted quality of life,” Guadagnoli said.
The findings demonstrate how psychological processes, such as hypervigilance and anxiety, may play a significant role in predicting symptom severity and treatment outcomes for patients with achalasia.
Screening patients for hypervigilance and anxiety may, therefore, help indicate which patients could benefit from early psychological interventions to improve post-treatment outcomes, Guadagnoli said.
“What would be a beautiful model is if people who have achalasia are screened and those who are reporting high levels of hypervigilance and anxiety meet with a psychologist in the clinic, even just for a few sessions, to try and address the vigilance and anxiety and any other psychological processes, either before treatment or while they’re going through treatment and recovering from treatment, to hopefully prevent these processes from amplifying symptoms,” Guadagnoli said.
Guadagnoli said next steps for this work will include investigating the underlying mechanisms of how these psychological processes interact with physiology and how that contributes to better or worse patient outcomes.
John Pandolfino, MD, ‘94 ‘96 GME, chief and the Hans Popper Professor of Gastroenterology and Hepatology in the Department of Medicine, was senior author of the study. Dustin Carlson, MD, ‘15 MS, ‘12 GME, assistant professor of Medicine in the Division of Gastroenterology and Hepatology, was a co-author of the study.
This work was supported by grant R01 DK137775 from the Public Health Service (National Institute of Diabetes and Digestive and Kidney Diseases).
