Achalasia Management Guidelines

Achalasia Management Guideline

• Achalasia is a primary esophageal motor disorder
• Unknown etiology, characterized by myenteric plexus degeneration
• Impaired relaxation of esophagogastric junction (EGJ)
• Loss of esophageal peristalsis
• Dysphagia (difficulty swallowing) and regurgitation are common symptoms
• Equal prevalence in males and females
• Globally reported incidence varies from .03 to 1.63 per 100,000 persons annually
• Higher incidence rates (2.92/100,000 in Central Chicago, 2.3-2.8/100,000 in South Australia) with more recent, advanced diagnostic techniques
• Symptoms in achalasia include dysphagia for solids and liquids in 90% of patients, regurgitation in 75%, weight loss in 60%, chest pain in 50%, and heartburn in 40%.
• Endoscopy is mandatory for achalasia diagnosis to rule out pseudoachalasia or mechanical obstructions in the EGJ
• High-resolution esophageal manometry is the gold standard for diagnosis
• Incomplete relaxation of the EGJ coupled with the absence of organized peristalsis is diagnostic of achalasia
• Three subtypes of achalasia are defined based on high-resolution manometry findings in the esophageal body: type I (classic), type II (pan-esophageal pressurization), and type III (high-amplitude spastic contractions).
• Treatment efficacy is dependent on these subtypes
• Treatment options include: botulinum toxin injection, pneumatic dilation, laparoscopic Heller myotomy, and per-oral endoscopic myotomy (POEM)
• POEM is often the preferred treatment for type III achalasia
• EndoFLIP (endoluminal functional lumen imaging probe) is a new technology assess mechanical properties of esophagus and EGJ. Provides impedance planimetry measurements of luminal cross-sectional area and pressure.
• This technology may contribute to a better evaluation of achalasia patients

Treatment Modalities

• Botulinum toxin injection:
  • Reduces LES pressure by inhibiting acetylcholine release.
  • Generally safe, with rare serious adverse events.
  • Short-term relief (months).
• Pneumatic dilation:
  • Disrupts LES fibers through intraluminal balloon dilation.
  • Typically performed under fluoroscopic guidance.
  • May need multiple dilations/balloon sizes.
  • Potential complications include esophageal perforation and bleeding.
• Laparoscopic Heller myotomy:
  • Surgical procedure disrupting the LES fibers.
  • Partial fundoplication often performed for improved outcomes.
  • Often is more effective in the long term.
• Per-oral endoscopic myotomy (POEM):
  • Minimally invasive procedure.
  • Disrupts LES fibers through an endoscopic approach.
  • Often chosen as a first-line treatment for many achalasia cases.
  • Reportedly high success rates and low complication rates

Comparative Treatment Outcomes

• Comparative data is currently lacking between these different treatment options
• Treatment efficacy and safety varies greatly among treatment modalities depend heavily on a single center's experience
• POEM may be better than other treatment choices in terms of cost-effectiveness over time, though a broader comparative analysis is needed
• Treatment success rates may vary based on achalasia subtype and various factors
• The choice between treatment modalities should be personalized based on achalasia type, patient preferences, and factors such as expertise of the treating personnel and local resources

This quiz covers the key aspects of achalasia, a primary esophageal motor disorder characterized by impaired relaxation of the esophagogastric junction. Learn about the symptoms, diagnostic methods, and management strategies associated with this condition. Perfect for medical students and healthcare professionals looking to enhance their understanding of achalasia.