From the Guidelines
Achalasia cardia should be treated with Per-oral Endoscopic Myotomy (POEM) as the preferred treatment for type III achalasia, and POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia, with the decision between these treatment modalities based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. The most recent and highest quality study, published in 2024 in the journal Gastroenterology 1, provides the best evidence for this recommendation.
Treatment Options
- POEM is a newer, less invasive option with promising results, and it should be considered the preferred treatment for type III achalasia.
- Laparoscopic Heller myotomy and pneumatic dilation are also effective therapies for type I and type II achalasia.
- The decision between these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise.
Diagnostic Workup
- Patients evaluated for POEM should undergo a comprehensive diagnostic workup, which includes clinical history and review of medications, upper endoscopy, timed barium esophagram, and high-resolution manometry, as recommended by the 2024 study in Gastroenterology 1.
- Endoscopic functional luminal impedance planimetry can be a useful adjunct test, particularly in cases when diagnosis is equivocal.
Post-Procedure Care
- Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting, given the increased risk of postprocedure reflux and esophagitis, as recommended by the 2024 study in Gastroenterology 1.
- All patients should undergo monitoring for gastroesophageal reflux disease after POEM, and patients with persistent esophagitis and/or reflux-like symptoms despite proton pump inhibitor use should undergo additional testing to evaluate for other etiologies besides pathologic acid exposure and management to optimize and achieve reflux control.
Long-Term Follow-Up
- Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease, as recommended by the 2024 study in Gastroenterology 1.
The 2024 study in Gastroenterology 1 also provides evidence that POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy, and the decision among treatment modalities should be based on shared decision making between the patient and physician, taking into account risk of postprocedural reflux, need for repeat interventions, patient preferences, and local expertise.
From the Research
Definition and Symptoms of Achalasia Cardia
- Achalasia cardia is a primary esophageal motor disorder of unknown cause that produces complaints of dysphagia, regurgitation, and chest pain 2, 3.
- It is characterized by impaired lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis 4.
Treatment Options for Achalasia Cardia
- The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure, resulting in improved esophageal emptying 2, 3.
- Treatment options include:
- Pneumatic dilation: a graded approach using Rigiflex balloons (3.0,3.5, and 4.0 cm) resulting in symptom improvement in up to 90% of patients 2, 3.
- Surgical myotomy: can be performed laparoscopically with similar efficacy to the open surgical approach, reduced morbidity, and hospitalization time 2, 3.
- Peroral endoscopic myotomy (POEM): a less invasive procedure that provides the endoscopist with the opportunity to adjust the length and orientation of esophageal myotomy according to the type of achalasia 5, 4.
- Botulinum toxin injection: should be reserved for patients who cannot undergo balloon dilation and are not surgical candidates 2, 3.
- Pharmacologic therapy: includes nitrates, calcium antagonists, and botulinum toxin, which may be effective in some patients but are often temporizing at best 6.
Management and Diagnosis of Achalasia Cardia
- High resolution manometry allows for the characterization of the type of achalasia, which has important therapeutic implications 5.
- The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited 5.
- There is no curative treatment available for achalasia cardia, and treatment modalities are palliative in nature 5, 4.