From the Guidelines
Achalasia is a rare esophageal motility disorder characterized by the failure of the lower esophageal sphincter (LES) to relax properly and impaired peristalsis of the esophagus, leading to difficulty swallowing, regurgitation, chest pain, and weight loss. This condition is diagnosed using a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, with endoscopic functional luminal impedance planimetry (FLIP) as a useful adjunct test in equivocal cases 1. The exact cause of achalasia remains unknown, but it may involve damage to nerves in the esophagus, possibly from viral infections or autoimmune processes.
Key Characteristics and Diagnosis
- The condition makes it difficult for food and liquids to pass from the esophagus into the stomach, resulting in progressive difficulty swallowing (dysphagia), regurgitation of undigested food, chest pain, and weight loss.
- Diagnosis involves tests like barium swallow, esophageal manometry, and endoscopy, with high-resolution manometry (HRM) being the gold standard for diagnosis and defining the subtype of achalasia according to the Chicago classification system 1.
- A comprehensive evaluation is paramount to confirm the diagnosis before consideration of treatment options like per-oral endoscopic myotomy (POEM), which should be performed by experienced physicians in high-volume centers 1.
Treatment Options and Considerations
- Treatment options include medications to relax the LES, endoscopic procedures such as pneumatic dilation or Botox injection, and surgical interventions like Heller myotomy.
- The choice of treatment depends on the patient's age, overall health, and severity of symptoms, with POEM considered the preferred treatment for type III achalasia and a viable option for types I and II, based on shared decision making and local expertise 1.
- Patients undergoing POEM should be advised of the potential risk of developing reflux esophagitis and the need for management considerations such as proton pump inhibitor therapy and/or surveillance endoscopy 1.
Complications and Quality of Life
- Without treatment, achalasia can lead to complications including aspiration pneumonia, esophagitis, and in rare cases, an increased risk of esophageal cancer due to chronic inflammation.
- Effective treatment can significantly improve the quality of life for patients with achalasia, reducing symptoms and the risk of complications, as demonstrated by the efficacy of POEM, laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) in multiple studies 1.
From the Research
Definition and Characteristics of Achalasia
- Achalasia is a primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body 2, 3.
- It typically presents with symptoms such as dysphagia, regurgitation, chest pain, and weight loss 2, 4, 3, 5, 6.
- The diagnosis of achalasia is suggested by barium swallow and endoscopy, and confirmed by manometry 2, 5, 6.
Clinical Symptoms and Diagnosis
- Patients with achalasia often experience dysphagia for solids and liquids, bland regurgitation, and chest pain 4, 5.
- Other less specific symptoms can also present, including heartburn, chronic cough, and aspiration pneumonia 4.
- High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy 6.
Treatment Options
- There is no curative treatment for achalasia, and treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage 2.
- Treatment modalities available for achalasia include pneumatic dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM) 2, 3, 6.
- Botulinum toxin injection into the lower esophageal sphincter and smooth muscle relaxants are usually reserved for older patients or those with co-morbid illness 5.