| Type I and II achalasia |
PD, LHM are both highly efficacious and durable in RCT; PD has less morbidity and cost With PD, anticipate repeat dilations over the years LHM may be preferable with advanced esophageal dilatation, sigmoidization, epiphrenic diverticulum, hiatal hernia POEM highly efficacious in short-term RCT vs PD Expect more reflux after POEM, especially with hiatal hernia |
| Type III achalasia |
|
| EGJ outflow obstruction |
Many cases resolve spontaneously: treat conservatively Image the EGJ (EUS, CT) to rule out obstruction Consider whether or not this is an opiate effect If achalasia therapies are applied, consider it type II achalasia |
| Absent contractility deemed to be achalasia |
Use timed barium esophagram, and/or multiple repetitive swallows on HRM to establish the need for treatment If achalasia therapies are applied, consider it type I achalasia |
| DES/Jackhammer |
Smooth muscle relaxants: nitrates, Ca++ channel blockers, PDE-5 inhibitors Consider EUS guided Botox injection to the spastic segment If achalasia therapies are applied, consider it type III achalasia POEM, calibrated the length of myotomy to the hypercontractile segment as imaged on HRM or thickened segment on EUS |
| Opioid effect |
|
| Obstruction |
Many entities mimic achalasia, sometimes termed ‘pseudoachalasia’: eosinophilic esophagitis, cancer, reflux stricture, post-myotomy stricture, etc. Conventional dilation Operative reversal if relevant; directed medical therapy if relevant |
