What is the diagnosis and treatment approach for a patient suspected of having achalasia?

From the Guidelines

Achalasia diagnosis and treatment should involve a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, with treatment focused on relieving the lower esophageal sphincter obstruction, and peroral endoscopic myotomy (POEM) should be considered the preferred treatment for type III achalasia. The diagnostic workup for achalasia should include:

• Clinical history and review of medications to establish the quality and severity of symptoms
• Upper endoscopy to rule out malignancy and assess esophageal clearance
• Timed barium esophagram to show structural changes and confirm outflow obstruction
• High-resolution manometry to confirm the diagnosis and define the subtype of achalasia according to the current Chicago classification system 1 Treatment options for achalasia include:
• Endoscopic interventions such as pneumatic dilation or POEM
• Surgical intervention with laparoscopic Heller myotomy, often combined with a partial fundoplication
• Botulinum toxin injection into the lower esophageal sphincter for temporary relief
• Calcium channel blockers or nitrates taken before meals for modest symptomatic relief 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, with POEM being the preferred treatment for type III achalasia 1. Some key considerations in the treatment of achalasia include:
• 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)
• POEM provides the advantage of unlimited proximal extension of myotomy, although long-term outcomes on “long myotomies” are limited
• Post-POEM patients should be considered high risk to develop reflux esophagitis and advised of the management considerations before undergoing the procedure 1.

From the Research

Diagnosis of Achalasia

• Achalasia is a primary disorder of esophageal motility, characterized by dysphagia to both solids and liquids, regurgitation, and chest pain 2, 3, 4, 5, 6.
• The gold standard for diagnosis is esophageal motility testing with manometry, which reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation 2, 3, 4, 5, 6.
• Complimentary tests, such as esophagogastroduodenoscopy and contrast radiography, aid in diagnosis and rule out mimickers of the disease, known as "pseudoachalasia" 2, 3, 4, 5, 6.
• Barium esophagography may reveal a dilated esophagus with a distal tapering, giving it a "bird's beak" appearance 2, 3, 4, 5, 6.

Treatment Approach

• Multiple therapeutic modalities are available for the management of achalasia, including medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy 2, 3, 4, 5, 6.
• Pneumatic dilation and Heller myotomy are considered the most definitive treatment options 2, 3, 4, 5, 6.
• New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy 2, 5, 6.
• The decision on which treatment to use depends on operative risk factors, and age, sex, and manometric type are predictors of responsiveness to treatment 5.