What are the types and treatment options for achalasia?

From the Guidelines

Achalasia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the esophageal body, with three main types: Type I, Type II, and Type III, each with distinct characteristics and treatment outcomes. The types of achalasia are:

• Type I (classic achalasia): shows minimal contractility in the esophageal body
• Type II: features pan-esophageal pressurization
• Type III (spastic achalasia): is characterized by premature or spastic contractions Treatment options aim to reduce lower esophageal sphincter pressure to improve emptying, and include:
• Pharmacological options: calcium channel blockers like nifedipine (10-30 mg) taken 30 minutes before meals, or nitrates such as isosorbide dinitrate (5-10 mg) before eating
• Endoscopic treatments: pneumatic dilation, which forcibly stretches the sphincter, and peroral endoscopic myotomy (POEM), which cuts the muscle fibers of the sphincter
• Botulinum toxin injection into the sphincter (100 units) can provide relief for 3-6 months and is particularly suitable for elderly patients or those unfit for more invasive procedures
• Surgical intervention with laparoscopic Heller myotomy, often combined with a partial fundoplication to prevent reflux, remains the gold standard treatment with success rates of 90-95% 1 POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia, while POEM should be considered the preferred treatment for type III achalasia. Patients should be monitored for complications like gastroesophageal reflux disease following treatment 1. Key considerations in treatment selection include patient and disease characteristics, patient preferences, and local expertise.

From the Research

Types of Achalasia

• There are three main types of achalasia: type I, type II, and type III, which can be distinguished using high-resolution manometry (HRM) 2, 3, 4.
• Type I achalasia is characterized by minimal esophageal pressurization, type II by esophageal compression, and type III by spasm 2.
• These subtypes have distinct manometric patterns and may respond differently to treatment 2, 5.

Treatment Options

• Treatment options for achalasia include pneumatic dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM) 3, 6, 5.
• The choice of treatment may depend on the subtype of achalasia, with type II responding well to all therapies and type III responding best to POEM 5.
• Treatment aims to disrupt the lower esophageal sphincter to improve bolus passage, as there is no curative treatment for achalasia 6.

Clinical Significance

• The clinical significance of achalasia subtypes is still being established, with some studies suggesting that subtyping may not be necessary for treatment decisions 3.
• However, other studies suggest that optimal management of achalasia is phenotype-specific, guided by HRM and functional luminal imaging probe studies 5.
• Further research is needed to fully understand the implications of achalasia subtypes for treatment and patient outcomes 4, 5.