Management

Achalasia is incurable. Treatment can be directed at relief of the distal obstruction:

• pharmacological treatment (1,2):
  • intrasphincteric injection of botulinum toxin should be considered as the initial therapy for patients with idiopathic achalasia who are at high risk for the complications of pneumatic dilatation or surgical myotomy
  • calcium channel blockers – block smooth muscle contraction
  • nitrates – increase nitric oxide concentration leading to relaxation
  • phosphodiesterase-5 inhibitors – reduce sphincter pressure
• endoscopic hydrostatic or pneumatic dilatation - this is with a balloon on the end of an endoscope, repeated monthly; most cost-effective (1,3).
• Heller's operation – endoscopic myotomy - cut distal 3 to 4 cm of oesophageal muscle longitudinally; the operation has a success rate of about 90% in those who do not respond to dilatation (3).

Both of the latter two treatments may produce subsequent reflux oesophagitis.

Reference:

1. Momodu II, Wallen JM. Achalasia. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519515/ - article-17083.s4 (accessed 21 January 2022)
2. Schlottmann F, Patti MG. Esophageal achalasia: current diagnosis and treatment. Expert Rev Gastroenterol Hepatol. 2018 Jul;12(7):711-721. doi: 10.1080/17474124.2018.1481748. Epub 2018 Jun 8. PMID: 29804476.
3. Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Am J Gastroenterol. 2020 Sep;115(9):1393-1411. doi: 10.14309/ajg.0000000000000731. PMID: 32773454.