What is the best treatment option for a 34-year-old woman with achalasia, normal lab results, and no medical problems, presenting with progressive dysphagia?

Best Treatment for Achalasia in a Young, Healthy Patient

Pneumatic dilatation is the best initial treatment option for this 34-year-old woman with achalasia who has no medical comorbidities. 1, 2

Rationale for Pneumatic Dilatation

For young, healthy patients with type I or II achalasia (the most common subtypes), pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM) are both highly efficacious, but PD has lower morbidity and cost. 1, 2 The 2018 UK guidelines specifically recommend starting with a 30 mm balloon in the first session to reduce complications, followed by a second session 2-28 days later with a 35 mm balloon. 1, 2

Expected Outcomes with Pneumatic Dilatation

• PD achieves 90% effectiveness in the first year, with long-term success rates of 97% at 5 years and 93% at 10 years when repeat dilations are performed as needed. 1, 2
• Up to one-third of patients may experience symptom recurrence during 4-6 years of follow-up, but the vast majority can be successfully retreated with repeat dilatation. 1, 2
• The perforation risk is 3-4% with mortality <1%, and post-dilatation reflux is usually mild and readily controlled with acid suppression. 1

Why Not the Other Options?

Fundoplication (Option A)

• Fundoplication alone does not address the primary pathophysiology of achalasia (impaired LES relaxation and absent peristalsis). 3
• It is typically combined with surgical myotomy as an antireflux procedure, not used as standalone therapy. 4

Oral Isosorbide Dinitrate (Option C)

• Medical therapy with nitrates provides only variable and disappointing long-term results due to tolerance and side effects. 5, 6
• Smooth muscle relaxants are much less effective than invasive procedures and are rarely used as long-term therapy. 6, 4

Botulinum Toxin Injection (Option D)

• Botulinum toxin should be reserved specifically for elderly patients or those at high surgical risk who are not candidates for myotomy or pneumatic dilation. 1, 7
• It has modest long-term results compared to other options and frequently requires repeated injections. 1, 7
• In this young, healthy 34-year-old patient, botulinum toxin would be inappropriate as first-line therapy. 5, 8

Important Clinical Considerations

Post-Procedure Management

• Consider proton pump inhibitor therapy after dilatation, as the technique has a 10-40% rate of symptomatic gastroesophageal reflux disease or ulcerative esophagitis. 1
• Monitor for at least 2 hours post-procedure and provide contact information for the on-call team. 1

When to Consider Surgical Options

• If PD fails after 2-3 sessions (Eckardt score remains >3), surgical myotomy should be considered. 1
• Laparoscopic Heller myotomy provides excellent long-term symptom control (90-95% good to excellent relief) but requires hospitalization and has higher upfront costs. 1, 6

Role of Achalasia Subtype

• If this patient has type III achalasia (spastic achalasia), POEM would be the preferred treatment due to the ability to perform a longer myotomy. 1, 2
• However, without manometry subtyping specified, and given that type I and II are most common, PD remains the most appropriate initial choice. 1, 2

Common Pitfall

The most common error is using botulinum toxin or medical therapy in young, healthy patients when definitive treatments (PD or surgical myotomy) are clearly superior and appropriate. 1, 7, 5