From the Guidelines
Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the esophagus, typically presenting with difficulty swallowing, regurgitation, chest pain, and weight loss. Diagnosis is usually confirmed through a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, as recommended by the American Gastroenterological Association (AGA) 1. The primary goal of treatment is to improve esophageal emptying and relieve symptoms.
Treatment Options
The most effective treatments for achalasia are per-oral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD), with the decision among these treatment modalities based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise 1.
- POEM is considered the preferred treatment for type III achalasia, as it provides the advantage of unlimited proximal extension of myotomy, which is beneficial for patients with spastic body contractions capable of luminal obliteration.
- LHM and PD are effective therapies for type I and type II achalasia, with similar success rates, and the choice between them should be based on individual patient factors.
- Botulinum toxin injection into the lower esophageal sphincter can provide temporary relief for patients who are not candidates for these interventions, typically lasting 6-12 months.
Management and Follow-up
Patients should be advised to eat slowly, chew thoroughly, and remain upright for several hours after eating to aid in esophageal emptying. Avoiding foods that commonly cause difficulty, such as very hot or cold items, may also help manage symptoms. Regular follow-up is important to monitor for potential complications like esophageal cancer, which has a slightly increased risk in achalasia patients. Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting, given the increased risk of postprocedure reflux and esophagitis 1. Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease.
From the Research
Definition and Characteristics of Achalasia
- Achalasia is a primary esophageal motor disorder of unknown cause that produces complaints of dysphagia, regurgitation, and chest pain 2.
- It is a chronic incurable esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis 3.
- Achalasia is a rare esophageal disorder characterized by abnormal esophageal motility and swallowing difficulties 4.
Symptoms of Achalasia
- Symptoms of achalasia include dysphagia to both solids and liquids, regurgitation, aspiration, chest pain, and weight loss 3.
- Pain and/or spasms often persist or recur despite effective relief of the obstruction 4.
Diagnosis of Achalasia
- Diagnosis of achalasia is based on an appropriate clinical presentation and typical findings on complementary tests, including endoscopy, High-resolution manometry (HRM), and barium swallow 5.
- HRM has permitted more precise diagnosis of achalasia and three subtype designations, based on the pattern of esophageal motility disorders, as per the Chicago Classification 5.
Treatment Options for Achalasia
- Treatment options include drugs, endoscopic procedures such as Botox injection or balloon dilation, and traditional surgery, laparoscopic Heller myotomy (LHM) 5.
- Per-oral endoscopic myotomy (POEM) is a novel, less invasive therapy that has been introduced as an excellent first-line treatment 5.
- Pneumatic dilation, Heller myotomy, and POEM are the most effective treatment options for achalasia, with POEM increasingly emerging as the treatment of choice for many patients 3.
- Calcium channel blockers or nitrates may be helpful in managing achalasia-related pain/spasms when esophageal obstruction and reflux have been excluded 4.