Achalasia

A summary of the most recent ACG (American College of Gastroenterology) guidelines for the diagnosis and management of achalasia

Background

Achalasia is a primary esophageal motor disorder of unknown etiology characterized manometrically by insufficient relaxation of the lower esophageal sphincter (LES) and loss of esophageal peristalsis; radiographically by aperistalsis, esophageal dilation, with minimal LES opening, “ bird-beak ” appearance, poor emptying of barium; and endoscopically by dilated esophagus with retained saliva, liquid, and undigested food particles in the absence of mucosal stricturing or tumor.

Diagnosis
  • The diagnosis of achalasia is supported by esophagram findings including dilation of the esophagus, a narrow esophagogastric junction with “bird-beak” appearance, aperistalsis, and poor emptying of barium (strong recommendation, moderate-quality evidence).
  • All patients with suspected achalasia who do not have evidence of a mechanical obstruction on endoscopy or esophagram should undergo esophageal motility testing before a diagnosis of achalasia can be confirmed (strong recommendation, low-quality evidence).
  • Endoscopic assessment of the gastroesophageal junction and gastric cardia is recommended in all patients with achalasia to rule out pseudoachalasia (strong recommendation, moderate-quality evidence).
Management
  • Either graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy for the treatment of achalasia in those fit and willing to undergo surgery (strong recommendation, moderate-quality evidence).
  • Botulinum toxin therapy is recommended in patients who are not good candidates for more definitive therapy with PD or surgical myotomy (strong recommendation, moderatequality evidence).
  • Pharmacologic therapy for achalasia is recommended for patients who are unwilling or cannot undergo definitive treatment with either PD or surgical myotomy and have failed botulinum toxin therapy (strong recommendation, low-quality evidence).
Follow-up
  • Patient follow-up aft er therapy may include assessment of both symptom relief and esophageal emptying by barium
    esophagram (strong recommendation, low-quality evidence).
  • Surveillance endoscopy for esophageal cancer is not recommended (strong recommendation, low-quality evidence).

Achalasia Algo

Am J Gastroenterol 2013; 108:1238–1249; doi:10.1038/ajg.2013.196; published online 23 July 2013