What are the management options for achalasia?

Management Options for Achalasia

The optimal management of achalasia should be tailored based on achalasia subtype, with POEM (per-oral endoscopic myotomy) being the preferred treatment for type III achalasia, while pneumatic dilation, laparoscopic Heller myotomy, and POEM are all effective options for type I and II achalasia. 1

Diagnostic Workup

Before selecting treatment, a comprehensive diagnostic evaluation is essential:

• High-resolution manometry (HRM): Gold standard for diagnosis and classification of achalasia subtypes
• Timed barium esophagram: Evaluates esophageal emptying and degree of dilation
• Upper endoscopy: Rules out pseudoachalasia (e.g., malignancy, eosinophilic esophagitis)
• Functional luminal impedance planimetry (FLIP): Useful adjunct when diagnosis is equivocal 1

Treatment Options by Achalasia Subtype

Type I and Type II Achalasia

Three equally effective primary treatment options:

1. Pneumatic Dilation (PD)

   • Advantages: Less morbidity, lower cost, non-surgical 1
   • Limitations: May require repeat dilations over time
   • Efficacy: Highly efficacious in randomized controlled trials

2. Laparoscopic Heller Myotomy (LHM)

   • Advantages: Durable response, can be combined with anti-reflux procedure
   • Limitations: More invasive, requires general anesthesia
   • Efficacy: Comparable to PD in randomized trials

3. Per-Oral Endoscopic Myotomy (POEM)

   • Advantages: No abdominal incisions, rapid recovery
   • Limitations: Higher risk of post-procedure reflux (up to 58% in some studies) 1
   • Efficacy: Highly efficacious with symptom improvement in 89-97% of patients 1

Type III Achalasia

POEM is the preferred treatment due to ability to perform longer myotomy to address the spastic segment 1

• Myotomy length should be calibrated to the spastic segment as imaged on HRM or thickened segment on EUS

Special Considerations

Esophagogastric Junction (EGJ) Outflow Obstruction

• Many cases resolve spontaneously (20-40%)
• Further imaging of EGJ recommended (EUS, CT)
• If achalasia therapies are applied, treat as type II achalasia 1

Distal Esophageal Spasm (DES) or Jackhammer Esophagus

• If deemed to be achalasia-related, treat as type III achalasia
• POEM with myotomy calibrated to the spastic segment 1

Opioid-Induced Pseudoachalasia

Treatment algorithm:

1. First choice: Discontinue opioid
2. Second choice: Botulinum toxin injection
3. Third choice: POEM 1

Elderly or High-Risk Patients

• Botulinum toxin injection: Less invasive but temporary effect (3-6 months)
• Consider when other treatments are contraindicated 2

Post-POEM Management

• Patients should be considered high risk for reflux esophagitis
• Pharmacologic acid suppression strongly recommended post-procedure 1
• Patients should be informed about potential need for indefinite PPI therapy and/or surveillance endoscopy 1

Pitfalls and Caveats

1. Pseudoachalasia: Always rule out malignancy and other secondary causes before proceeding with treatment
2. Post-POEM reflux: Higher rates compared to LHM with fundoplication; patients need counseling and monitoring
3. Expertise matters: POEM should be performed by experienced physicians in high-volume centers (20-40 procedures needed to achieve competence) 1
4. Recurrence after PD: Anticipate need for repeat dilations over time
5. Advanced disease: Most published treatment trials excluded end-stage cases with significant esophageal dilation 1

The choice between treatment options should be based on achalasia subtype, patient characteristics, and available expertise, with POEM being particularly advantageous for type III achalasia due to its ability to address the spastic component of the disease.