A Case Illustrating the Natural Progression of Type III to Type II Achalasia
Bibliographic record
Abstract
Achalasia is characterized by loss of esophageal peristalsis and impaired lower esophageal sphincter (LES) relaxation. Progressive loss of nitrergic inhibitory innervation in the esophagus likely plays a major role in the progression of achalasia (1). This hypothesis is supported by histological studies in patients diagnosed with achalasia, in whom there is a decrease of neurons containing nitric oxide synthase and interstitial cells of Cajal, a unit that likely modulates nitrergic nerve response (2, 3). Given that the normal physiology of esophageal peristalsis and LES relaxation is dependent on nitrergic innervation (4), it has been hypothesized that achalasia naturally progresses from spastic type III, to pan-pressurization seen in type II, and finally, to loss of esophageal pressurization in advanced type I achalasia (5). To date, there is no data supporting the hypothesis of disease progression between achalasia subtypes. We report a case of a previously healthy 60-year-old male who presented with dysphagia and was subsequently diagnosed with type III achalasia by high-resolution esophageal manometry study (EMS) (Figure 1A). Following the initial diagnosis, he underwent two pneumatic dilatations without any significant clinical improvement of his dysphagia. Two years later, a repeat EMS demonstrated type II achalasia (Figure 1B). High-resolution esophageal manometry study of the index case: (A) demonstrating type III achalasia at the initial visit; (B) progressing into type II achalasia in the subsequent study two years later. This is the first longitudinal clinical case that demonstrates the progression from type III to type II achalasia. It not only strengthens our current understanding of the natural history of achalasia but also supports the hypothesis of the loss of nitrergic inhibitory innervation in the pathogenesis of achalasia.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.003 | 0.002 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.002 | 0.002 |
| Research integrity | 0.007 | 0.004 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".