New Guideline for Treating Achalasia

Guideline Watch |
September 27, 2013

New Guideline for Treating Achalasia

  1. David A. Johnson, MD

Toward a more tailored approach to treatment

  1. David A. Johnson, MD

Sponsoring Organization: The American College of Gastroenterology (ACG)

Target Population: Gastroenterologists and esophageal surgeons

Background and Objective:

Authors provide up-to-date, evidence-based recommendations for the diagnosis and management of achalasia, a primary esophageal motility disorder that is chronic, progressive, and marked by relapse.

Key Points:

  • In one third of patients, endoscopy results may be normal or barium swallow may be nondiagnostic.

  • Variants occur, marked by differing degrees of incomplete LES relaxation and aperistalsis or by complete lower esophageal sphincter (LES) relaxation.

  • Timed barium esophagram (retained contrast at 5 minutes) is useful in identifying incomplete response to therapy despite reported symptomatic improvement.

  • Graded pneumatic dilation (PD) or laparoscopic myotomy with partial fundoplication, performed at high-volume centers of excellence, is preferred therapy for surgical candidates.

  • Botulinum toxin (Botox) should be reserved for those who are not PD or surgery candidates and may be contraindicated in case of severe egg protein allergy.

  • After PD, all patients must undergo radiographic testing with gastrograffin, followed by dilute barium swallow to exclude perforation.

  • PD is the most cost-effective treatment.

  • Treatment should be directed toward effective esophageal emptying and continually reassessed for adequacy to avoid end-stage megaesophagus.

  • Surveillance endoscopy for esophageal cancer screening is not recommended.

  • Peroral esophageal myotomy (POEM) is a promising alternative to surgery, but more safety, efficacy, and comparative data are needed.

What's Changed: Treatment recommendations focus more broadly on both nonsurgical and surgical methods that should be tailored to the patient. In contrast, the previous guideline from the Society of American Gastrointestinal and Endoscopic Surgeons (available at strongly recommended laparoscopic myotomy with partial fundoplication as the procedure of choice for patients with achalasia, stating that it provided “superior and longer-lasting symptom relief with low morbidity for patients with achalasia compared with other treatment modalities” (Surg Endosc 2012; 26:296).


This guideline is comprehensive and well done. The available evidence supporting some of the recommendations, however, is scant or even lacking and therefore defaults to expert opinion. Of particular note, although the routine use of radiologic testing after pneumatic dilation may not be universal among experts, in my opinion, it is absolutely nonnegotiable when PD is performed in an outpatient setting.

Editor Disclosures at Time of Publication

  • Disclosures for David A. Johnson, MD at time of publication Consultant / Advisory board Abbott; Centacor; CRH Medical; Medscape; Pfizer; Takeda Pharmaceuticals Speaker's bureau Takeda Pharmaceuticals Editorial boards ACG Universe; MedScape Gastroenterology


Reader Comments (2)

dalesouth jr MD Physician, Family Medicine/General Practice, elkhart IN

Personally received Heller procedure @Northwestern 2005 with only overnight stay in hosp. Have had no serious complications.
would recommend it as a procedure.

Kristin Karcher Other Healthcare Professional, Internal Medicine, DoD

Appreciate the new guidelines;

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