What is the best treatment approach for a patient with suspected achalasia, presenting with esophageal spasm?

Treatment Approach for Suspected Achalasia with Esophageal Spasm

If high-resolution manometry confirms type III achalasia (spastic achalasia), per-oral endoscopic myotomy (POEM) is the definitive preferred treatment, as it allows unlimited proximal extension of the myotomy tailored to the spastic segment, achieving 92% response rates. 1, 2

Diagnostic Workup Required Before Treatment

Before proceeding with any intervention, you must complete a comprehensive diagnostic evaluation to confirm achalasia and determine the subtype 1, 3:

• Upper endoscopy (EGD): Look for dilated esophageal lumen, retained food/fluid, and carefully examine the gastroesophageal junction in retroflexion to exclude pseudoachalasia from occult malignancy 3, 4
• Timed barium esophagram: Confirms outflow obstruction, demonstrates structural changes (dilation, sigmoid deformity), and reveals subtle narrowing at the EGJ 1, 3
• High-resolution manometry (HRM): Gold standard for diagnosis and critical for subtype classification according to Chicago Classification—this determines your treatment approach 1, 3
• Functional luminal impedance planimetry (FLIP): Useful adjunct when diagnosis is equivocal, showing impaired EGJ opening with low distensibility index 1

Treatment Algorithm Based on Achalasia Subtype

Type III Achalasia (Spastic—Your Clinical Scenario)

POEM is the definitive first-line treatment when expertise is available 1, 2:

• The myotomy length must be calibrated to the proximal extent of the spastic segment visualized on HRM or thickened segment on endoscopic ultrasound, typically 12-16 cm 1, 2
• Type III achalasia responds consistently worse to standard LES-only therapies (pneumatic dilation, standard Heller myotomy) because the obstructive physiology includes the distal esophagus with spastic contractions, not just the LES 1, 2, 5
• Critical requirement: POEM must be performed by experienced physicians in high-volume centers, as 20-40 procedures are needed to achieve competence 1, 3

If POEM is unavailable: Laparoscopic Heller myotomy can be considered but must be extended proximally to address the spastic component, with generally inferior results compared to POEM 2

Pneumatic dilation has limited efficacy in type III achalasia and is not recommended as primary therapy for this subtype 2

Type I and II Achalasia (If Diagnosed Instead)

For these subtypes, POEM, laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) are all effective first-line options 1, 5:

• Pneumatic dilation: 90% first-year success, 97% at 5 years with repeat dilations; lower upfront morbidity and cost but anticipate repeat procedures over years 1, 3
• Laparoscopic Heller myotomy with partial fundoplication: Comparable efficacy to PD with lower reflux rates but higher upfront cost 3
• POEM: Superior to PD in randomized trials, noninferior to LHM, but highest reflux risk 1

Critical Post-Treatment Management

Gastroesophageal Reflux Management (Mandatory)

All patients undergoing POEM must receive pharmacologic acid suppression immediately post-procedure 1, 3:

• POEM carries the highest reflux risk among all achalasia treatments, with 58% showing gastroesophageal reflux on pH-metry and 10-40% developing symptomatic GERD or ulcerative esophagitis 1, 2, 3
• Patients require counseling about potential indefinite proton pump inhibitor therapy and surveillance endoscopy before undergoing POEM 1, 2, 5
• Monitor all patients for reflux esophagitis; those with persistent symptoms despite PPI should undergo additional testing to evaluate for other etiologies 1

Antibiotic Prophylaxis

A single dose of antibiotics at the time of POEM is sufficient 1, 2

Discharge Planning

Same-day discharge can be considered in select patients meeting discharge criteria, but those with advanced age, significant comorbidities, poor social support, or limited access to specialized care should be admitted 1

Important Caveats and Pitfalls

Do not treat based on manometry alone if esophagogastric junction outflow obstruction (EGJOO) is the only finding: EGJOO without other achalasia features can resolve spontaneously and has multiple alternative causes (obesity, hiatal hernia, GERD, external compression) 1. POEM for EGJOO should only be considered case-by-case after exhausting less invasive approaches 1

Avoid standard LES-only directed therapy for type III achalasia: This is the most critical error, as it consistently yields poor outcomes by failing to address the spastic esophageal body component 5

Advanced disease considerations: In patients with sigmoid achalasia or severe esophageal dilation, POEM can be attempted but with doubled risk of adverse events and reduced expectations; esophagectomy should be considered for sigmoid achalasia with severe dilation as it addresses irreversible structural changes 2, 3