Management of achalasia

Management of achalasia aims to reduce the pressure in the lower oesophageal sphincter so that the passage of food is improved. This can be achieved by either myotomy (laparoscopic or peroral endoscopic) or pneumatic balloon dilatation. These are equally effective in relieving dysphagiaBoeckxstaens, 2011. Peroral endoscopic myotomy (POEM) is associated with a higher rate of postprocedural gastro-oesophageal reflux, but this can be managed with acid suppression (see Management of frequent or severe symptoms of gastro-oesophageal reflux disease (GORD) in adults). POEM appears to be more effective for one subtype of achalasia (Type III) than laparoscopic myotomy, probably due to division of a longer segment of oesophageal muscle.

Injection of botulinum toxin type A into four quadrants of the lower oesophageal sphincter improves symptoms, but may need to be repeated at intervals of 3 to 12 months. It is generally used when other therapies are not suitable.

Drugs that relax the lower oesophageal sphincter (eg nitrates, calcium channel blockers) may be trialled (see Distal oesophageal spasm for suitable regimens); however, they are of limited benefit. These drugs may also be associated with significant gastrointestinal and cardiovascular adverse effects (eg hypotension).

Achalasia has been associated with an increase in oesophageal squamous carcinoma, possibly due to ongoing inflammation secondary to food retention. Refer the patient to a gastroenterologist or gastrointestinal surgeon as ongoing endoscopic surveillance with biopsy and treatment of areas of dysplasia may be appropriate in some patients.