Achalasia, from diagnosis to treatment

ABSTRACT

Introduction

Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation.

Areas covered

The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy.

Expert opinion

Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.

KEYWORDS:

• Dysphagia
• achalasia
• diagnosis
• high resolution manometry (HRM)
• management
• per oral endoscopic myotomy (POEM)

Article highlights

• Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter relaxation.

• The most common symptoms reported by patients with achalasia include progressive dysphagia, regurgitation of esophageal content, non-cardiac chest pain, respiratory symptoms, and weight loss.

• High resolution manometric diagnosis of achalasia is based on the absence of LES relaxation in combination with aperistalsis of the esophageal body.

• Endoscopic pneumatic dilation of the LES is a valuable option among non-surgical treatments for achalasia.

• POEM has gained popularity and may be considered as an effective strategy in the achalasia therapeutic armamentarium, particularly in young patients and in those with type III achalasia.

• Laparoscopic Heller myotomy (LHM) is a first-line treatment for achalasia treatment based on the dissection of the LES smooth muscle fibers.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.