Diagnosis and Management of Achalasia: Updates of the Last Two Years

Abstract

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Keywords: achalasia; diagnosis; dysphagia; high resolution manometry (HRM); management; per oral endoscopic myotomy (POEM).

Figure 1

A five milliliter water swallow starts with the opening of the upper esophageal sphincter (UES). One normal esophageal peristalsis and normal lower esophageal sphincter (LES) relaxation is shown. The LES relaxation is measured over a 10 s period, as shown in the box, by measuring the median integrated relaxation pressure (IRP) (supplied from the gastroenterology department at EMMS Nazareth hospital).

Figure 2

The three achalasia subtypes determined by the Chicago classification (supplied from the gastroenterology department at EMMS Nazareth hospital).