Current Diagnosis and Management of Achalasia

Abstract

Achalasia is the best characterized primary esophageal motility disorder of the esophagus and typically presents with absent peristalsis of the esophageal body and a failure of the lower esophageal sphincter to relax upon swallowing on manometry, associated with progressively severe dysphagia, regurgitation, aspiration, chest pain, and weight loss. The diagnosis is suggested by barium swallow and endoscopy, and confirmed by manometry. As there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. Treatment modalities available for this purpose include pneumatic dilation, laparoscopic Heller myotomy and since recently peroral endoscopic myotomy or POEM. In this review, we will discuss the current diagnosis, management, and treatment options of achalasia.

Imaging of the oesophagus: beyond cancer

“…Loss of the ganglion cells leads to an overall decreased inhibitory neuronal signal to the smooth muscle resulting in impaired primary and secondary peristalsis and increased tone of the LES. The combination of impaired oesophageal motility and distal narrowing secondary to increased LES tone ultimately results in dilatation of the lumen [10]. The classic manifestation of achalasia on imaging is the “bird beak sign,” referring to the tapering of the inferior oesophagus resembling the beak of a bird (Fig.…”

Update on therapeutic interventions for the management of achalasia

“…Clinical features include dysphagia to solids and liquids, regurgitation of food and/or saliva, chest pain, and weight loss . Dysphagia is seen in 90% of patients, regurgitation in 75%, weight loss in 60%, chest pain in 40–50%, and heartburn in 40% .…”

“…Achalasia is a primary esophageal motility disorder characterized by absent peristalsis of the esophageal body and failure of relaxation of the lower esophageal sphincter. 1,2 Although achalasia is rare, it is the most common esophageal motility disorder with an estimated incidence of 1 per 100 000. 3 Achalasia affects both sexes and all races equally 4 and does not appear to have a predilection for any age group.…”

“…4,5 Clinical features include dysphagia to solids and liquids, regurgitation of food and/or saliva, chest pain, and weight loss. 1,2 Dysphagia is seen in 90% of patients, regurgitation in 75%, weight loss in 60%, chest pain in 40-50%, and heartburn in 40%. 6 Pathognomic findings at gastroscopy include the presence of retained salivary secretions or food content despite prolonged fasting.…”

Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes

“…Published success rates vary widely depending on age, Chicago classification subtype, and disease duration but long-term symptomatic relief has been achieved in 40-80% of patients undergoing PD with protocols including serial treatments 5 and between 80-90% for LHM. 6,7 The use of contrast esophagography to evaluate for leak after both PD and LHM has been described extensively, given the high sensitivity of the test for detection of esophageal perforation, the most concerning complication for either procedure. In addition to excluding a leak, the posttreatment esophagram also allows the radiologist to provide a qualitative assessment of esophageal emptying by observing the passage of contrast after each swallow.…”