Achalasia

Obtain esophagogastroduodenoscopy in every patient with suspected achalasia before definitive therapy. A retained saliva-filled esophagus and a puckered, tightly closed gastroesophageal junction support the diagnosis, but the critical procedural purpose is exclusion of pseudoachalasia from an obstructing mass. PubMed+1PubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCPubMedAn Overview of Achalasia and Its Subtypes - PMC

Confirm primary achalasia with high-resolution manometry (HRM): impaired esophagogastric junction relaxation together with absent organized esophageal peristalsis establishes the diagnosis. HRM is the current gold standard and separates clinically relevant subtypes. ScienceDirect+2ScienceDirectPharmacologic Therapy in Treating Achalasia - ScienceDirectPubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCPubMedAn Overview of Achalasia and Its Subtypes - PMC

Use a timed barium esophagram when HRM is equivocal, when anatomy needs characterization before intervention, or when symptoms recur after therapy. In a symptomatic patient, aperistalsis, esophageal dilation, and distal "bird-beak" narrowing are characteristic radiographic findings. Wolters Kluwer+2Wolters KluwerACG Clinical Guideline: Diagnosis and Management... : American Journal of GastroenterologyPubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCPubMedACG clinical guideline: diagnosis and management of achalasia - PubMed

For treatment-naive type I or II achalasia, offer pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), or peroral endoscopic myotomy (POEM) as definitive options. The selection should explicitly weigh patient preference, local procedural expertise, anticipated need for retreatment, and risk of postprocedural reflux. PubMed+1PubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

POEM is the preferred treatment for type III achalasia. Its endoscopic myotomy can be extended to address the spastic esophageal segment, whereas outcomes with conventional LHM and PD have historically been more limited in type III disease. jtcvs+1jtcvsPeroral endoscopic myotomy provides effective palliation in type III ...ScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

When LHM is selected, perform an anterior fundoplication with the myotomy. This operative approach is intended to relieve dysphagia while mitigating the reflux consequence of an unopposed surgical myotomy. JAMA+1JAMALaparoscopic Heller Myotomy and Anterior Fundoplication for ...Oxford AcademicPeroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review | Diseases of the Esophagus | Oxford Academic

Discuss reflux explicitly when choosing POEM. Comparative evidence shows more post-treatment GERD symptoms and more endoscopic esophagitis after POEM than after LHM; in a large randomized comparison, the odds ratio for endoscopic esophagitis at 24 months was 2.00. Oxford AcademicOxford AcademicPeroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review | Diseases of the Esophagus | Oxford Academic Post-POEM reflux may be endoscopic rather than symptom-detected, so absence of heartburn does not exclude clinically relevant reflux injury. Oxford Academic+1Oxford AcademicPeroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review | Diseases of the Esophagus | Oxford AcademicScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

For persistent or recurrent dysphagia after PD, LHM, or POEM, reassess symptoms with the Eckardt score and obtain objective testing rather than selecting repeat therapy from symptoms alone. Timed barium esophagram and repeat HRM help identify persistent esophagogastric junction outflow obstruction, while endoscopy evaluates retained contents, inflammatory injury, structural complications, and alternative pathology. ScienceDirect+2ScienceDirectPharmacologic Therapy in Treating Achalasia - ScienceDirectPubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

After failed LHM, POEM is a reasonable salvage option. In a multicenter randomized study with 5-year follow-up after failed LHM, treatment success was 40% with POEM versus 11% with PD; grade B through D reflux esophagitis occurred in 11% and 9%, respectively. ScienceDirectScienceDirectLong-Term Outcomes of Peroral Endoscopic Myotomy vs Pneumatic Dilation After Prior Laparoscopic Heller Myotomy for Achalasia

After POEM, actively monitor for GERD, including endoscopic esophagitis. Persistent esophagitis or reflux-like symptoms despite proton pump inhibitor therapy should trigger testing for etiologies other than pathologic acid exposure and adjustment of reflux management rather than assuming inadequate acid suppression is the sole explanation. ScienceDirectScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

At follow-up, document the Eckardt score and determine whether dysphagia, regurgitation, chest pain, or weight loss has recurred. Pair clinically meaningful symptom recurrence with timed barium esophagram, HRM, and/or endoscopy according to the suspected mechanism rather than using symptoms alone to define procedural failure. ScienceDirect+2ScienceDirectPharmacologic Therapy in Treating Achalasia - ScienceDirectPubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMCScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

Maintain particular surveillance for reflux complications after POEM because esophagitis can occur without proportionate reflux symptoms. Persistent esophagitis warrants reassessment and management aimed at demonstrable reflux or an alternate cause. Oxford Academic+1Oxford AcademicPeroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review | Diseases of the Esophagus | Oxford AcademicScienceDirectBlown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

Achalasia is associated with esophageal squamous cell carcinoma, but routine endoscopic cancer screening is not recommended by ACG and ASGE guidance because absolute cancer yield is low; one estimate suggested more than 400 endoscopies would be required to detect one cancer. New progressive symptoms, unexplained weight loss, or suspicious endoscopic findings should instead prompt diagnostic evaluation for malignancy. Wolters Kluwer+1Wolters KluwerAchalasia: A Risk Factor for Esophageal Squamous Cell... : Official journal of the American College of Gastroenterology | ACGPubMedACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMC