Achalasia

Achalasia occurs at any age but usually begins between ages 20 and 60. Onset is insidious, and progression is gradual over months or years. Dysphagia for both solids and liquids is the major symptom. Nocturnal regurgitation of undigested food occurs in about 33% of patients and may cause cough and pulmonary aspiration. Chest pain is less common but may occur on swallowing or spontaneously. Mild to moderate weight loss occurs; when weight loss is pronounced, particularly in older patients whose symptoms of dysphagia developed rapidly, pseudoachalasia secondary to a tumor of the gastroesophageal junction should be considered.

(See also the American College of Gastroenterology’s 2020 practice guidelines on the diagnosis and management of achalasia.)

Esophageal manometry Manometry Manometry is measurement of pressure within various parts of the gastrointestinal tract. Manometry is done by passing a catheter containing solid-state or liquid-filled pressure transducers... read more is the preferred diagnostic test for achalasia. This test shows incomplete relaxation of the LES with a median integrated relaxation pressure ≥ 15, and 100% failed peristalsis.

Barium swallow is a complementary test that is often done during the initial phase of testing when the cause of dysphagia is unknown because manometry is more invasive. Barium swallow may show absence of progressive peristaltic contractions during swallowing. Typically, the esophagus is dilated, often enormously, but is narrowed and beaklike at the LES.

Esophagoscopy is often done. Findings include upstream esophageal dilation and chronic stasis changes in the mucosa but no obstructing lesion. A classic "pop" is often felt when the esophagoscope passes into the stomach.

Impedance planimetry Impedance Planimetry (See also Manometry.) Impedance planimetry provides real-time assessment of luminal distensibility and geometric changes in response to applied pressure in various parts of the gastrointestinal... read more , when available, can be used to evaluate achalasia and can provide useful diagnostic information where manometry is nondiagnostic or if the patient cannot tolerate manometry. Recent guidelines recommend its use in the diagnosis and management of achalasia (1 Diagnosis references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more , 2 Diagnosis references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more ). Additionally, in patients undergoing interventions for achalasia (eg, surgery, peroral endoscopic myotomy), measurement of esophagogastric junction distensibility during and after the intervention accurately measures clinical response to interventions and can help guide therapy.

Achalasia must be differentiated from a peptic stricture, particularly in patients with systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more , in whom esophageal manometry may also show aperistalsis. Systemic sclerosis is usually accompanied by a history of Raynaud phenomenon Raynaud Syndrome Raynaud syndrome is vasospasm of parts of the hand in response to cold or emotional stress, causing reversible discomfort and color changes (pallor, cyanosis, erythema, or a combination) in... read more and symptoms of gastroesophageal reflux disease Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more (GERD) due to low resting LES pressure.

Symptoms similar to those of achalasia (ie, pseudoachalasia) may be due to cancer at the gastroesophageal junction, which can be diagnosed by CT of the chest and abdomen or by endoscopic ultrasound with biopsy.

Esophageal dilation and tortuosity are poor prognostic indicators. Pulmonary aspiration is a late-stage complication. Nocturnal regurgitation and coughing suggest aspiration. Pulmonary complications secondary to aspiration are difficult to manage. Incidence of esophageal cancer in patients with achalasia is not currently thought to be increased.

No therapy restores peristalsis; treatment of achalasia is aimed at reducing the pressure at the LES.

Pneumatic balloon dilation of the LES and surgical or peroral endoscopic myotomy appear similarly effective. In 2016, a randomized, controlled trial involving achalasia patients found that at 5-year follow-up pneumatic balloon dilation had comparable efficacy to laparoscopic Heller myotomy (1 Treatment references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more ). A posthoc analysis of these data according to achalasia subtypes found better results with pneumatic balloon dilation for patients with type II achalasia (swallowing increases pressure in the entire esophagus) and better results with Heller myotomy for type III achalasia (spastic achalasia; swallowing often results in lumen-obliterating contractions). Both procedures produced similar outcomes in patients with type I achalasia (classic achalasia; swallowing results in no change in esophageal pressure) (1 Treatment references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more , 2 Treatment references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more ). The most concerning complication of these procedures is esophageal perforation. Perforation rates vary by center, ranging from 0 to 14% for pneumatic balloon dilation and 0 to 4.6% for laparoscopic Heller myotomy (3 Treatment references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more ). Other current studies have shown peroral endoscopic myotomy to have good short-term and long-term outcomes (4 Treatment references Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis and a lack of lower esophageal sphincter relaxation during swallowing. Symptoms are slowly... read more ). However, postprocedure gastroesophageal reflux disease rates are higher in patients who undergo peroral endoscopic myotomy than in those who undergo Heller myotomy. Thus, the ideal treatment option is based on achalasia subtype, procedure risk, and potential adverse effects.

In patients who are not candidates for these treatment options, chemical denervation of cholinergic nerves in the distal esophagus by direct endoscopic injection of botulinum toxin type A into the LES may be tried. Clinical improvement occurs in 70 to 80% of patients; results may last 6 months to over 1 year.

Drugs such as nitrates or calcium channel blockers have been used in the past but have not been shown to be effective.

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.