COMMENTARY

Achalasia: Evolving Concepts in Diagnosis and Management

David A. Johnson, MD

Disclosures

September 09, 2013

In This Article

A Tough Problem to Swallow

Achalasia, the best known primary esophageal motility disorder, is a chronic, progressive, and -- even after successful treatment -- relapsing condition that causes severe morbidity and is often difficult to manage. The disorder is best defined by the manometric cardinal features of aperistalsis and impaired relaxation of the lower esophageal sphincter (LES).

To date, the primary treatment has focused on the pathologic obstruction at the LES, with targeted disruption by either endoscopic or surgical methods. Irrespective of primary treatment modality (pneumatic dilation [PD] or surgery), this disorder has a substantial relapse rate, ranging from 25% to 30% at 5 years and up to 50% at 10 years following treatment. Several recent publications provide key new insights for clinicians dealing with these patients.

Recently, the manometric features of the residual esophageal wave patterns of achalasia have been classified by high-resolution manometry, with a shift in emphasis from the standard manometric pressure assessment of the LES toward the Chicago classification,[1] which uses criteria to analyze the pressure topography of the esophageal body assessed by high-resolution manometry. Three manometric subtypes are described:

Type I: Minimal contractility of the esophageal body without distal pressurization;

Type II: Aperistalsis, but intermittent periods of compartmentalized panesophageal pressurization; and

Type III: Spastic contractions and periods of panesophageal pressurization.

It has been suggested that the subtype classification is an important determinant of treatment success and should be used to best direct modality for intervention.

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