Achalasia Management
A 34-year-old woman has had 8 months of progressive dysphagia to both solids and liquids and regurgitation of undigested food at night. Barium swallow shows bird-beak narrowing at the gastro-oesophageal junction, and high-resolution manometry confirms absent peristalsis with failure of lower oesophageal sphincter relaxation. Upper endoscopy excludes malignancy. She is fit for any intervention. Which of the following is the most effective definitive treatment?
- A.Laparoscopic Nissen fundoplication
- B.Endoscopic botulinum toxin injection
- C.Oral isosorbide dinitrate before meals
- D.Graded pneumatic balloon dilatationCorrect
Explanation
Achalasia results from loss of inhibitory nitrergic ganglion cells in the myenteric plexus, producing failure of lower oesophageal sphincter relaxation and absent oesophageal peristalsis. Definitive treatment must mechanically disrupt the sphincter, and in a young fit patient the durable options are graded pneumatic balloon dilatation, laparoscopic Heller myotomy with partial fundoplication, or per-oral endoscopic myotomy. Among the choices offered, graded pneumatic dilatation is the only durable sphincter-disrupting therapy and achieves symptomatic remission in about 70 to 90 percent of patients, although repeat sessions are often needed and oesophageal perforation occurs in roughly 2 percent. Botulinum toxin injection blocks acetylcholine release and lowers sphincter pressure but its effect lasts only 6 to 12 months, so it is reserved for elderly or frail patients unfit for dilatation or surgery. Oral nitrates and calcium channel blockers give modest, short-lived relief with frequent headache and hypotension, and are palliative only. Nissen fundoplication is an antireflux operation that would tighten an already non-relaxing sphincter and worsen the obstruction, so it is contraindicated as primary therapy; when a Heller myotomy is performed, a partial (Dor or Toupet) wrap is added instead. Pseudoachalasia from a gastro-oesophageal junction tumour must always be excluded by endoscopy before intervention, and patients need long-term follow-up because of a small increased risk of oesophageal squamous carcinoma.
Why each option
- A.
- Nissen fundoplication tightens the gastro-oesophageal junction and would aggravate obstruction; only a partial wrap is used, and only after a myotomy.
- B.
- Botulinum toxin lowers sphincter pressure temporarily for 6 to 12 months and is reserved for frail patients who cannot undergo dilatation or myotomy.
- C.
- Nitrates and calcium channel blockers give only modest short-lived symptom relief with headache and hypotension, and are palliative rather than definitive.
- D.
- Correct. Graded pneumatic dilatation mechanically disrupts the lower oesophageal sphincter and gives durable relief in most young fit patients with achalasia.
Reference: ACG Clinical Guideline: Diagnosis and Management of Achalasia, 2020
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