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Presentation, Diagnosis, and Management of Achalasia

January 24, 2016

Presentation, Diagnosis, and Management of Achalasia


Dr. Pandolfino, et. al have written a nice summary of Achalasia detailing diagnosis, treatment, and follow-up.


His comments about management of Achalasia are as follows:


"Patients who are deemed to be in otherwise good health should be counseled to pursue a definitive treatment capable of alleviating EGJ outflow obstruction such as myotomy (laparoscopic or endoscopic) or pneumatic dilation." Unfortunately, this is yet again another paper which mentions nothing about lifestyle in the management of Achalasia.


He makes this comment about follow-up. "Patients should have a postprocedure evaluation of effectiveness within the first 3 months after the intervention to assess adequacy of functional and symptom response. The importance of combining subjective findings of symptom reduction and objective findings evaluating esophageal retention and continued EGJ outflow obstruction was highlighted in work published by Vaezi et al46 that assessed long-term outcome in patients after pneumatic dilation. They reported that patients with concordance of symptom improvement and minimal bolus retention on timed barium esophagogram had good long-term improvement, whereas patients with discordance of improved symptoms but poor bolus emptying on timed barium esophagogram had a worse long-term prognosis and were more prone to return with symptoms."


"Achalasia is not cured by current treatments [Emphasis added], and patients should be monitored for progression of esophageal dilatation and development of megaesophagus or sigmoid esophagus, often referred to as end-stage achalasia."


This commentary is very important: "Surgical series report that an estimated 10%–15% of patients who have undergone treatment for achalasia eventually fulfill criteria for end-stage achalasia54 and that up to 5% of patients may require esophagectomy.55 However, these are historical data and likely not reflective of current management practices. Nonetheless, even though it seems logical that successful treatment of achalasia reduces the risk of developing end-stage achalasia, there are no relevant substantiating data. Similarly, there are no data supporting that routine of follow-up studies (endoscopy, barium studies, manometry, esophageal scintigraphy) predict or prevent progression to end-stage achalasia. [emphasis added]"


Was is of concern to us is that there is no agreed upon long term follow-up protocol or ways to manage Achalasia after any of the medical "treatmenmts." 


Please see my book for ways to manage Achalasia.






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