Approach to initial management of adults with achalasia

Options for therapy include mechanical disruption of the LES (eg, myotomy or pneumatic dilation) or pharmacologic reduction in LES pressure (eg, botulinum toxin injection or oral nitrate). Mechanical disruption of the LES has been associated with more durable results. In addition to efficacy, the choice of intervention is informed by patient characteristics, patient preferences, institutional expertise, and safety. Refer to UpToDate content on management of achalasia for additional details.

PEP: panesophageal pressurization; LES: lower esophageal sphincter; ASA: American Society of Anesthesiologists; GERD: gastroesophageal reflux disease; POEM: peroral endoscopic myotomy; SL: sublingual.

* The preprocedure evaluation includes a medical history, anesthesia-directed physical examination, and assessing ASA physical status. Refer to UpToDate content on anesthesia for gastrointestinal endoscopy for details.

¶ Higher rates of GERD are reported after POEM than either laparoscopic myotomy or pneumatic dilation. This may be a consideration for younger patients and for those who do not want long-term therapy with a proton pump inhibitor.

Δ The length of the myotomy can be tailored to the length of the spastic esophageal segment as demonstrated on diagnostic studies (eg, high resolution manometry, functional lumen imaging probe).

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Approach to initial management of adults with achalasia