Current treatment options for achalasia vary based on disease severity and patient factors, focusing on relieving symptoms by reducing lower oesophageal sphincter (LOS) pressure.
For mild to moderate achalasia, initial management often includes pneumatic balloon dilation or pharmacological therapy such as calcium channel blockers or nitrates, which provide temporary symptom relief but are less durable long-term options NICE CKS.
In more severe or refractory cases, or when less invasive treatments fail, laparoscopic Heller myotomy combined with partial fundoplication is considered the gold standard surgical treatment, offering durable symptom control by mechanically disrupting the LOS muscle fibers NICE CKS.
Peroral endoscopic myotomy (POEM) has emerged as a less invasive alternative to surgery, particularly effective in severe achalasia or type III achalasia subtypes, providing comparable efficacy to Heller myotomy with potentially fewer complications Zaninotto et al. 2018.
Botulinum toxin injection into the LOS is generally reserved for patients who are unfit for surgery or endoscopic interventions due to comorbidities, as its effects are temporary and symptoms often recur Zaninotto et al. 2018 NICE CKS.
Choice of treatment is influenced by achalasia subtype (determined by high-resolution manometry), patient age, comorbidities, and local expertise, with more aggressive interventions favored in severe disease to improve long-term outcomes NICE CKS Zaninotto et al. 2018.
Key References
- CKS - Dyspepsia - proven GORD
- NG231 - Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management
- NG83 - Oesophago-gastric cancer: assessment and management in adults
- CKS - Dyspepsia - unidentified cause
- CG184 - Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management
- (Zaninotto et al., 2018): The 2018 ISDE achalasia guidelines.