# Achalasia

Confirm suspected achalasia with high-resolution manometry after excluding mechanical obstruction, then select pneumatic dilation, laparoscopic Heller myotomy with fundoplication, or POEM by subtype, anatomy, reflux tradeoff, prior therapy, and local expertise.

**Clinical question:** How should physicians confirm achalasia, exclude pseudoachalasia, choose definitive therapy, and evaluate persistent symptoms after treatment?

Updated: 2026-09-16T00:39:26.756899+00:00

## What matters in practice
- Perform upper endoscopy in suspected achalasia to exclude an obstructing mass causing pseudoachalasia; retained saliva and a puckered gastroesophageal junction are supportive findings, not confirmatory tests. [13][15]
- High-resolution manometry is the diagnostic gold standard and identifies the achalasia subtype that informs treatment selection. [13][15]
- For type I or II achalasia, POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective definitive options; select through shared decision-making that includes expertise, retreatment expectations, and postprocedure reflux risk. [13][19]
- Prefer POEM for type III achalasia because conventional Heller myotomy and pneumatic dilation have historically had less successful outcomes in this spastic subtype. [17][19]
- Do not use botulinum toxin as routine durable therapy when the patient can undergo definitive treatment; its benefit commonly lasts only months. [5]
- Recurrent dysphagia after myotomy or dilation requires objective reassessment for residual outflow obstruction, reflux-related injury, progressive dilation, or an alternative diagnosis rather than empiric repeat intervention. [13][19]

## Confirm achalasia and exclude pseudoachalasia before LES-directed therapy

Do not treat a manometric pattern as idiopathic achalasia until structural obstruction has been assessed.

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. [13][15]

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. [5][13][15]

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. [4][13][14]
- Do not label dysphagia as refractory GERD solely because heartburn is present; achalasia can be erroneously diagnosed as gastroesophageal reflux disease. [8]
- Treat esophagogastric junction outflow obstruction without absent peristalsis as a separate manometric finding requiring symptom correlation and comprehensive evaluation; evidence for POEM in this setting is limited and should be individualized after less invasive approaches are exhausted. [19]

*Tests that change the next diagnostic or therapeutic step in suspected achalasia. [4][13][15][19]*

| Test | Actionable finding | What it changes |
| --- | --- | --- |
| Upper endoscopy | Retained saliva with puckered gastroesophageal junction supports achalasia; obstructing lesion raises pseudoachalasia. [13][15] | Exclude mechanical obstruction before LES-disrupting therapy; investigate a detected mass rather than proceeding directly to dilation or myotomy. [15] |
| High-resolution manometry | Impaired EGJ relaxation plus absent organized peristalsis confirms achalasia and identifies subtype. [5][13][15] | Use subtype in procedure selection; type III favors POEM. [15][19] |
| Timed barium esophagram | Dilated, aperistaltic esophagus with distal bird-beak narrowing in a symptomatic patient. [4][14] | Defines anatomic retention and provides an objective comparator when evaluating post-treatment symptoms. [13] |

## Choose LES-disrupting therapy by subtype, durability, reflux risk, and procedural context

All established therapies are palliative and reduce outflow resistance at the nonrelaxing lower esophageal sphincter.

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. [13][19]

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. [17][19]

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. [3][10]

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. [10] Post-POEM reflux may be endoscopic rather than symptom-detected, so absence of heartburn does not exclude clinically relevant reflux injury. [10][19]
- Reserve endoscopic botulinum toxin injection for patients who cannot undergo definitive therapy or require temporary palliation; it is generally safe, but response is transient, commonly lasting several months. [5]
- Pharmacologic therapy is not a durable substitute for LES-disrupting treatment. Available options include pharmacotherapy, botulinum toxin injection, PD, LHM, and POEM, but definitive mechanical therapies provide durable palliation for appropriate candidates. [5][16]
- Use the Eckardt score to standardize symptom burden and clinical response across visits; it sums dysphagia, regurgitation, chest pain, and weight loss on a 0-to-12 scale. [5][15]

*Practical selection among established achalasia interventions. [5][10][13][17][19]*

| Intervention | Best-fit clinical context | Key tradeoff |
| --- | --- | --- |
| POEM | Preferred for type III achalasia; also an effective option for type I or II disease. [17][19] | Higher postprocedure GERD symptoms and endoscopic esophagitis than LHM in comparative studies; arrange reflux surveillance. [10][19] |
| Laparoscopic Heller myotomy with anterior fundoplication | Effective definitive option for type I or II achalasia when surgical therapy is appropriate. [3][13][19] | Requires laparoscopy but includes an antireflux procedure; comparative data favor lower reflux burden than POEM. [3][10] |
| Pneumatic dilation | Effective definitive option for type I or II disease, particularly when an endoscopic, nonmyotomy strategy is preferred. [13][19] | May require repeat treatment; outcomes are less favorable than POEM in some comparisons and are not preferred for type III disease. [7][17][19] |
| Botulinum toxin injection | Temporary palliation when definitive treatment is unsuitable. [5] | Effective in about two-thirds of patients but typically lasts only months. [5] |

## Re-evaluate objectively before retreatment after dilation or myotomy

Persistent dysphagia is not synonymous with recurrent LES obstruction.

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. [5][13][19]

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. [20]

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. [19]
- Consider residual or inadequate myotomy, recurrent LES obstruction, progressive esophageal dilation, reflux-related injury, and nonachalasia causes when treatment response is incomplete. Objective reassessment determines whether repeat LES therapy is appropriate. [13][19]
- Use shared decision-making for salvage treatment; prior intervention, reflux risk, disease anatomy, and local expertise should influence selection between repeat endoscopic, surgical, and dilation-based strategies. [19][20]

*Post-treatment symptoms: test-directed next steps. [13][19][20]*

| Clinical problem | Objective assessment | Management implication |
| --- | --- | --- |
| Persistent dysphagia after any intervention | Eckardt score, timed barium esophagram, repeat HRM, and endoscopy as indicated. [5][13][19] | Distinguish persistent obstruction from reflux injury, anatomic progression, or another disorder before retreatment. [13][19] |
| Failure after laparoscopic Heller myotomy | Confirm ongoing symptom burden and objective abnormality before salvage therapy. [13][20] | POEM produced higher 5-year treatment success than PD in a randomized post-LHM population. [20] |
| Esophagitis or reflux symptoms after POEM | Endoscopic assessment and further reflux evaluation when symptoms or esophagitis persist despite PPI therapy. [19] | Optimize reflux control and investigate nonacid or alternative causes when appropriate. [19] |

## Monitor treatment response, reflux injury, and progressive esophageal disease

Follow-up should target dysphagia recurrence and complications created by chronic stasis or LES-disrupting treatment.

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. [5][13][19]

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. [10][19]

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. [6][13]
- Do not describe current interventions as curative: PD, LHM, POEM, botulinum toxin, and pharmacologic options palliate symptoms by lowering outflow resistance. [16]
- Escalate new or progressive symptoms to endoscopy and objective physiologic/radiographic testing, especially when prior response was durable or when weight loss raises concern for pseudoachalasia or malignancy. [13][15]

*Follow-up priorities after definitive achalasia treatment. [5][6][10][13][19]*

| Follow-up target | Assessment | Action when abnormal |
| --- | --- | --- |
| Recurrent symptom burden | Eckardt score with targeted timed barium esophagram, HRM, or endoscopy. [5][13][19] | Identify the mechanism before repeating dilation or myotomy. [13][19] |
| Post-POEM reflux injury | Symptoms plus endoscopic assessment because esophagitis may not parallel symptoms. [10][19] | Treat and investigate persistent esophagitis or symptoms despite PPI therapy. [19] |
| Cancer concern | Diagnostic endoscopy for concerning new findings; do not use routine screening solely for achalasia. [6][13] | Evaluate for esophageal malignancy or pseudoachalasia when clinical concern is present. [13][15] |

## References
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2. Peroral Endoscopic Myotomy (POEM) vs Pneumatic Dilation ... — jamanetwork.com — https://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.2019.8858
3. Laparoscopic Heller Myotomy and Anterior Fundoplication for ... — jamanetwork.com — https://jamanetwork.com/journals/jamasurgery/fullarticle/390675
4. ACG Clinical Guideline: Diagnosis and Management... : American Journal of Gastroenterology — journals.lww.com — https://journals.lww.com/ajg/fulltext/2013/08000/acg_clinical_guideline__diagnosis_and_management.7.aspx?Ppt=Article%7Cajg%3A2013%3A08000%3A00007%7C10.1038%2Fajg.2013.196%7C
5. Pharmacologic Therapy in Treating Achalasia - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S1052515718300734
6. Achalasia: A Risk Factor for Esophageal Squamous Cell... : Official journal of the American College of Gastroenterology | ACG — journals.lww.com — https://journals.lww.com/ajg/fulltext/2016/10001/achalasia__a_risk_factor_for_esophageal_squamous.1688.aspx
7. Manage Consent Preferences — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S0016510724036344
8. Erroneous Diagnosis of Gastroesophageal Reflux Disease in Achalasia - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S1542356511004502
9. Extended indications and contraindications for peroral endoscopic myotomy — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S1096288313000351
10. Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review | Diseases of the Esophagus | Oxford Academic — academic.oup.com — https://academic.oup.com/dote/article/37/1/doad055/7236686
11. Efficacy and safety of pneumatic dilation in achalasia — journals.lww.com — https://journals.lww.com/00043897-201907000-00002
12. Symptomatic and Physiological Outcomes Following... - Ovid — journals.lww.com — https://journals.lww.com/surgical-laparoscopy/fulltext/2022/06000/symptomatic_and_physiological_outcomes_following.3.aspx
13. ACG Clinical Guidelines: Diagnosis and Management of Achalasia - PMC — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9896940
14. ACG clinical guideline: diagnosis and management of achalasia - PubMed — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/pubmed/23877351
15. An Overview of Achalasia and Its Subtypes - PMC — pmc.ncbi.nlm.nih.gov — https://pmc.ncbi.nlm.nih.gov/articles/PMC5572971
16. Achalasia - StatPearls - NCBI Bookshelf - NIH — www.ncbi.nlm.nih.gov — https://www.ncbi.nlm.nih.gov/books/NBK519515
17. Peroral endoscopic myotomy provides effective palliation in type III ... — www.jtcvs.org — https://www.jtcvs.org/article/S0022-5223(21)00229-4/pdf
18. Life in a world with per oral endoscopic myotomy — www.jtcvs.org — https://www.jtcvs.org/article/S0022-5223(20)30737-6/fulltext
19. Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0016510720346368
20. Long-Term Outcomes of Peroral Endoscopic Myotomy vs Pneumatic Dilation After Prior Laparoscopic Heller Myotomy for Achalasia — www.sciencedirect.com — https://www.sciencedirect.com/science/article/pii/S154235652600234X
21. Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S1542356519311073
22. Peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: 5-year follow-up of a randomised controlled trial - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S2468125322003004
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24. Comparison of Perioperative Outcomes Between Peroral Esophageal Myotomy (POEM) and Laparoscopic Heller Myotomy - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S1091255X2306972X

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.