Dysphagia

https://doi.org/10.1007/s00455-021-10297-1

REVIEW

Management of Esophageal Dysphagia in Chagas Disease

Roberto Oliveira Dantas1 

Received: 9 November 2020 / Accepted: 25 March 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Chagas disease, caused by the infection of the protozoan parasite Trypanosoma cruzi, has clinical consequences in the heart
and digestive tract. The most important changes in the digestive tract occur in the esophagus (megaesophagus) and colon
(megacolon). Esophageal dysfunction in Chagas disease results from damage of the esophageal myenteric plexus, with loss
of esophageal peristalsis, partial or absent lower esophageal sphincter relaxation, and megaesophagus, which characterizes
secondary esophageal achalasia. The treatment options for the disease are similar to those for idiopathic achalasia, consisting
of diet and behavior changes, drugs, botulinum toxin, peroral endoscopic myotomy (POEM), pneumatic dilation of the lower
esophageal sphincter, laparoscopic Heller myotomy, and esophagectomy. Chagas disease causes a life-threatening cardiopa-
thy, and this should be considered when choosing the most appropriate treatment for the disease. While some options are
palliative, for temporary relief of dysphagia (such as drugs, botulinum toxin, and pneumatic dilation), other therapies provide
a long-term benefit. In this case, POEM stands out as a modern and successful strategy, with good results in more than 90%
of the patients. Esophagectomy is the option in Chagas disease patients with advanced megaesophagus, despite the increased
risk of complications. In these cases, peroral endoscopic myotomy may be an option, which needs further evaluation.

Keywords  Chagas disease · Esophageal achalasia · Myotomy · Deglutition disorders

Introduction functions [11–13]. The most important changes occur in the

Chagas disease (American trypanosomiasis) was first
described in 1909 by the Brazilian physician Carlos Ribeiro
Justiniano das Chagas [1]. He made an important contribu-
tion to the knowledge of the disease that was named after
him. Chagas disease is endemic in Latin America [2, 3] and
has currently affected individuals in North America, Europe,
Japan, and Australia as well [2–10].
The disease, caused by the infection of the protozoan
parasite Trypanosoma cruzi, has clinical consequences in
the heart and the digestive tract [1, 2, 11, 12]. Manifestations
of Chagas disease in the digestive tract are seen in 10–15%
of chronically infected individuals [3] and include impaired
saliva production and changes in the pharyngeal, esophageal,
gastric, gallbladder, small bowel, and large bowel motor
* Roberto Oliveira Dantas
rodantas@fmrp.usp.br
1
Department of Medicine, Ribeirão Preto Medical School,
University of São Paulo, Av. Bandeirantes, 3900 – Campus
da USP, Ribeirão Preto, SP, Brazil
esophagus (megaesophagus) and colon (megacolon).
Esophageal dysfunction in Chagas disease results from
damage of the myenteric plexus (Auerbach’s plexus) [14,
15], with loss of esophageal peristalsis, partial or absent
lower esophageal sphincter (LES) relaxation, and megae-
sophagus, which altogether characterize secondary esopha-
geal achalasia [16–18]. Degeneration and loss of the myen-
teric plexus is a consequence of immune cross-reactivity of
the flagellar antigen of T. cruzi and myenteric neurons [19].
Achalasia secondary to Chagas disease and idiopathic
achalasia share similar features in terms of esophageal motor
dysfunction. It is marked by the absence of peristalsis and
failure of LES relaxation on swallowing, and their symptoms
(dysphagia, regurgitation, odynophagia, chest pain, weight
loss, and heartburn) [11, 18]. Hence, the treatment of idi-
opathic and Chagas disease achalasia is similar and aims to
decrease the intensity of dysphagia, improve the quality of
life, and maintain the patients’ nutrition and hydration. How-
ever, the diseases differ in intensity and imbalance between
excitatory and inhibitory innervation, probably due to differ-
ent pathophysiologies [20, 21]. The most striking difference
is in the LES pressure, which is low in most patients with

13
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Chagas’ disease and high in most patients with idiopathic
achalasia [22]. An evaluation with high-resolution manom-
etry described ineffective esophageal motility, fragmented
peristalsis, hypotonic lower esophageal sphincter, and hyper-
tonic upper esophageal sphincter [7].
In Chagas disease patients, changes in esophageal motil-
ity and esophageal retention may be present even in asymp-
tomatic patients [23]. Generally, no treatment is required
in this situation, although these patients may benefit from
avoiding dry and hard foods.
The treatment of T. cruzi-infected patients is controver-
sial. Although some drugs have been proposed, such as ben-
znidazole and nifurtimox, there is no hard evidence for their
positive effects in the long run [24, 25]. Using anti-parasite
drugs in the chronic phase of Chagas disease aims mostly
to prevent the progression of the cardiac form [26] and is
recommended in treatment guidelines [27]. On the other
hand, patients with the digestive form of the disease have
abnormalities of the myenteric plexus of the esophagus and
colon [14], and thus no beneficial effect of these drugs is
expected. There is no evidence that systemic pharmacologi-
cal treatment can reverse esophageal or colon dysfunction.
The objective of the treatment is to palliate symptoms—dys-
phagia in the case of megaesophagus and constipation in the
case of megacolon.
Two serologic tests are needed for reliable serologic diag-
nosis of T. cruzi infection [28] and exclusion of idiopathic
achalasia. Chagas disease as a cause of megaesophagus
should be investigated in Latin American migrants [9],
patients with associated cardiopathy, symptomatic and/or
with electrocardiographic changes, and with constipation
[12].
Management of Chagas’ Disease Patients
with Achalasia
Persistent dysphagia is seen in nearly 28% of the T. cruzi-
infected subjects without esophageal dilation [29] and in
almost all patients with megaesophagus. Relief of dyspha-
gia and maintenance of adequate nutrition and hydration
are the focus of the treatment of esophageal disease. The
results of each treatment depend on the severity of esopha-
geal dysfunction.
The degree of the megaesophagus is a reference when
deciding on a treatment. It is measured with radiology and
classified into grades I to IV, according to the esophageal
diameter and barium sulfate retention [16, 30], after inges-
tion of slightly thick (International Dysphagia Diet Stand-
ardization Initiative, IDDSI level 1) or mildly thick (IDDSI
level 2) liquid barium sulfate [31, 32]. The impairment of
esophageal function gradually worsens from grade I to IV
13
Roberto Oliveira Dantas: Esophageal Dysphagia in Chagas’ Disease
[16, 30]. High-resolution manometry is not yet a reference to
define the best treatment for Chagas disease megaesophagus.
The megaesophagus grade is one of the determinants for
treatment selection, with a more invasive treatment in grades
III and IV. However, it is possible to obtain good results with
Heller laparoscopic myotomy even in patients with intense
esophageal dilation [33].
Heart disease may be a limitation to invasive interven-
tions. Therapeutic options include diet, behavior changes,
drugs, endoscopy, pneumatic dilation, and surgery. In Cha-
gas disease, the severity of the esophageal disease, patients’
socioeconomic status, and cultural diversity should be con-
sidered in the therapeutic decision-making process.
Diet
Patients with Chagas disease-related esophageal dysphagia,
especially those with normal radiologic findings or mild dis-
ease (grade I or even grade II), may tolerate dysphagia for
a long time and decide not to undergo invasive treatment.
In these cases, dietary modification, particularly changes
in food consistency (IDDSI levels 0–4) [31, 32], may be
sufficient for hydration and nutrition, since swallowing is
preserved and esophageal retention is not so evident. Dietary
modification can be adopted for all patients, regardless of
the combination with other treatment options. In addition,
drinking water during or after meals may aid food ingestion.
Behavior Changes
All Chagas disease patients with dysphagia should be
instructed to change their diet and behavior, without exclud-
ing other treatment options. Patients should eat slowly,
standing or in an upright sitting position, chew food well,
and avoid hard and dry foods. Situations of stress, hurry, or
anxiety at mealtimes are not favorable. There is no set time
to wait to go to bed after meals, but patients should avoid
lying soon after them. In patients with the dilated esophagus
(grades II–IV), foods and saliva remain in the esophagus
for a long time and may reflux up to the pharynx and be
aspirated [34]. Performing body maneuvers, as Valsalva and
neck movements, and drinking water after the meal may help
the bolus pass through into the stomach.
Drugs
Smooth muscle relaxants have long been used in the treat-
ment of achalasia [35], especially nitrates and calcium chan-
nel blockers. They have a transient effect reducing the LES
pressure, though with potential side effects, including head-
ache and dizziness. In Chagas disease, the calcium chan-
nel blocker nifedipine (10 mg) [36] and isosorbide dinitrate
(5 mg) [37, 38] have proved to decrease LES pressure—an
Roberto Oliveira Dantas: Esophageal Dysphagia in Chagas’ Disease

effect that is faster, longer, and more intense with dinitrate. Table 1  Results of peroral endoscopic myotomy (POEM) in patients
On one hand, using isosorbide dinitrate can cause severe side with Chagas disease and idiopathic achalasia
effects without a significant improvement in the patient’s Chagas (n = 58) Idi-
well-being [39]. On the other hand, some patients expe- opathic
rience only mild side effects and benefit from significant (n = 31)
relief of dysphagia. Furthermore, although these drugs have Clinical success 96% 83%
been commonly used for patients who cannot be submitted Technical success 98% 77%
to other therapeutic strategies [40], the positive effects of Mean Eckardt score 1.55 3.40
these drugs are not expected to last for a long time. There- Mean LES pressure (mmHg) 12.3 17.3
fore, long-term clinical trials are needed to clarify this issue.
Other drugs used in the management of idiopathic acha- P < 0.04 for clinical and technical success. LES lower esophageal
sphincter
lasia, including loperamide, cimetropium, and sildenafil, can
The results are better in Chagas [44]
decrease LES pressure but they do not relieve dysphagia
[35].
Table 2  Results of peroral endoscopic myotomy (POEM) in patients
Endoscopy with Chagas disease and idiopathic achalasia
Chagas (n = 20) Idi-
Botulinum Toxin opathic
(n = 31)
Endoscopic injection of botulinum toxin in LES to treat idi- Clinical success 90% 93%
opathic achalasia is a safe procedure, though with a short- Mean Eckardt score 1.0 0.0
term efficacy [35]. It finds good dysphagia control response Mean LES pressure (mmHg) 10.3 10.7
in two-thirds of the patients, lasting for an average of Mean BMI (kg/m2) 27.1 26.0
1.3 years [41]. In Chagas megaesophagus, botulinum toxin Erosive esophagitis 35% 39%
injection leads to a clinical improvement of dysphagia and Adverse events 30% 12%
a decrease in esophageal emptying time, regardless of basal Length of hospital stay (days) 3.8 3.6
LES pressure [42]. Since basal LES pressure is already less-
ened in most Chagas disease patients with megaesophagus P > 0.16. LES lower esophageal sphincter
[7, 22], this therapeutic approach is expected to have a mini- BMI body mass index (kg/m2)
mal effect on them. Although endoscopic botulinum toxin The results are similar [45]
injection in LES is an easy procedure, there is no study on
the long-term effects of this approach in a large number of
Chagas disease patients. Thus, using botulinum toxin should treatment results in Chagas disease and idiopathic achalasia
be reserved for patients who cannot undergo any other treat- are shown in Tables 1 (for Ref. [44]) and 2 (for Ref. [45]).
ment option. Post-POEM gastroesophageal reflux may occur in 35% of
chagasic patients [45]. In idiopathic achalasia, POEM and
Peroral Endoscopic Myotomy (POEM) laparoscopic Heller myotomy have comparable efficacy,
except that POEM causes less serious adverse events than
The most recent option of esophageal achalasia treatment laparoscopic Heller myotomy and pneumatic dilation, and
is the peroral endoscopic myotomy (POEM), proposed by results in a higher rate of gastroesophageal reflux [46].
Haruhiro Inoue [43]. In POEM, a submucosal tunnel is cre-
ated to access the mediastinum through the esophageal wall.
Although it is a safe technique, POEM cannot prevent gas- Pneumatic Dilation of the LES
troesophageal reflux, which may be a major complication
of the procedure. Pneumatic dilation of the gastroesophageal junction was the
The clinical success rate of POEM in Chagas disease first option to treat chagasic achalasia and has long been
exceeds 90% [44, 45]. Some studies suggest that patients used so, as well as with idiopathic achalasia [35]. However,
with chagasic achalasia are 9.5 times more likely to respond this therapeutic approach requires repeated sessions, which
to POEM than patients with idiopathic achalasia [44]. In is not always possible for patients with Chagas disease, due
contrast, others have not described differences between idi- to socioeconomic limitations. Pneumatic dilation depends on
opathic and chagasic achalasia, with likewise impressive the expertise of the staff and, when performed by qualified
success in the parameters evaluated and no clear relation personnel, it has proved to be an inexpensive and effective
with megaesophagus grade [45]. Comparisons of POEM form of treatment [47, 48].

13

Comparisons with surgical treatments have described
that pneumatic dilation of the LES is comparable with lapa-
roscopic cardiomyotomy in terms of dysphagia relief and
gastroesophageal reflux rates [48]. There is a risk of esopha-
geal perforation after dilation, requiring careful procedure
and follow-up. The risk is higher in malnourished and heart
disease patients, in whom this treatment modality should
be avoided. Regardless of the therapy chosen for chagasic
megaesophagus, malnutrition should be corrected before an
invasive treatment is considered.
Laparoscopic Heller Myotomy
Laparoscopic Heller myotomy is the most frequent treat-
ment option for dysphagia in chagasic achalasia [49]. It is a
less invasive approach than open surgery, with a low risk of
complications and successful, long-lasting results in terms
of dysphagia relief [50]. The technique may be combined
with partial fundoplication to prevent post-myotomy gas-
troesophageal reflux.
Laparoscopic Heller myotomy is mostly indicated for
patients with grades I and II esophageal disease (i.e., mild
increase in esophageal diameter) and absence of ‘sigmoid’
megaesophagus—although it may be performed in the
dilated esophagus [33]. Laparoscopic myotomy has the same
success as myotomy performed by laparotomy [51].
Esophagectomy
In patients with esophageal disease grades III and IV (i.e.,
more severe increase in esophageal diameter in radiologic
examination), pneumatic dilation of the gastroesophageal
junction and surgical cardiomyotomy may not improve
dysphagia, at least in Chagas disease. So far, there are no
sufficient data to support POEM in Chagas’ disease as an
alternative to esophagectomy in patients with esophageal
disease grades III and IV. In idiopathic achalasia, laparo-
scopic Heller myotomy can be performed—although such
treatment for these particular patients is controversial [52].
In the case of severe megaesophagus (which is rare nowa-
days in Chagas disease, at least in Brazil), total or subtotal
esophagectomy and reconstruction with the stomach or an
intestinal segment is indicated [53]. This is a long and com-
plex surgery, requiring qualified personnel, and has a high
risk of morbidity and mortality [54]. One surgical treatment
option for these patients and those with recurrent dysphagia
is the Serra-Doria surgery [55, 56], which consists of a car-
dioplasty with Roux-en-Y gastrectomy. Although this pro-
cedure has a positive success rate in short-term follow-up, it
is associated with a high incidence of symptom recurrence
in the long run [57] and cardiovascular complications in
patients with Chagas disease [58]. Therefore, these inva-
sive procedures should be reserved for selected cases whose
13
Roberto Oliveira Dantas: Esophageal Dysphagia in Chagas’ Disease
patients would not benefit from other treatment modalities
and in whom dysphagia causes an important impairment in
the quality of life.
Considering the techniques to perform esophagectomy,
there is no difference between minimally invasive laparo-
scopic esophagectomy and open transhiatal esophagectomy,
in terms of benefits brought about by the treatment [59].
In cases of relapsed megaesophagus after myotomy, there
is the possibility of re-myotomy, Serra-Doria operation, or
esophagectomy [56].
Gastrostomy may be considered for Chagas disease
patients who are malnourished, advanced in age, and at high
risk of cardiac and other complications. It is a palliative
measure for nutritional and hydration support.
Lastly, it is worth mentioning that socioeconomic sta-
tus can influence the choice of treatment in Chagas disease
and consequently the course of the disease. In general, these
patients belong to low socioeconomic groups and may not
be able to receive prolonged treatments that involve repeated
sessions (e.g., botulinum toxin injection or pneumatic dila-
tion of the LES) due to poorer access to private and/or ter-
tiary public care centers. Dysphagia compromises the qual-
ity of life and may cause important limitations in everyday
life in different cultures [60]. It is important to reinforce
that there are no differences in the treatment possibilities
for idiopathic and Chagas disease achalasia. The treatment
should be individualized for each patient, considering the
risk–benefit assessment. POEM is a promising possibility
for the near future.
Declarations 
Conflict of Interest  The author declares no conflict of interest.
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Roberto Oliveira Dantas  MD