Pneumatic Dilation for Achalasia

Pneumatic Dilation for Achalasia

Anna Tavakkoli, MD, MSc

Achalasia is a primary esophageal motility disorder that is characterized by a loss of inhibitory neurons in the esophagus with subsequent tonic contraction of the lower esophageal sphincter (LES) and loss of esophageal peristalsis.1,2Although achalasia is a rare disorder, with an incidence of 1:100,000, recent reports suggest a two- to fourfold increase in incidence due to unclear reasons.1,2,3,4,5 Typically, achalasia is idiopathic without a clear inciting cause. However, achalasia can be termed secondary achalasia or pseudoachalasia if a defined etiology causing achalasia is found.6 Causes of secondary achalasia range from neoplastic disorders, infiltrative disorders such as amyloidosis, Chagas disease, or circulating antibodies, such as with small-cell lung cancer.1,6

Patients with achalasia typically present with dysphagia to liquids and solids and regurgitation of undigested foods.1,7 Since patients often present with dysphagia, an upper endoscopy, endoscopic ultrasound, and/or a barium esophagram are obtained to rule out a mechanical or infiltrative process. Endoscopic findings that are suggestive of achalasia include mega esophagus or significant dilation of the esophagus, presence of stasis-type mucosal changes, and in some cases, a subjective feeling of difficulty passing the endoscope through the LES.1,7 Barium esophagram will often show a dilated esophagus with an air-fluid level and narrowing at the gastroesophageal junction (GEJ), typically described as a “bird-beak” appearance.1,3,7 However, neither endoscopy nor barium esophagram can make a definitive diagnosis of achalasia, and esophageal manometry is considered the gold standard for diagnosis.

Based on the Chicago Classification of esophageal motility disorders, there are three types of achalasia: (1) type 1, characterized by an elevated median integrative relaxation pressure (IRP) with 100% failed peristalsis; (2) type 2, characterized by an elevated median IRP with 100% failed peristalsis and intermittent
pan-esophageal pressurization, involving greater than or equal to 20% of swallows; (3) type 3, characterized by an elevated median IRP, premature/spastic contractions involving greater than or equal to 20% of swallows, and no normal peristalsis.8 There are times where the results of esophageal impedance do not clearly indicate that a patient has achalasia. In those settings, the use of a functional lumen imaging probe (FLIP, Crospon, Galway, Ireland) can be performed. FLIP allows direct measurement of GEJ distensibility and diameter and can serve as a complementary test to aid in the diagnosis of achalasia.1,8

Treatment of achalasia aims at disrupting the hypertonic LES and include medical therapy, botulinum toxin, pneumatic dilation, per-oral endoscopic myotomy (POEM), and Heller myotomy. Since POEM offers achalasia patients a chance at durable symptom control, pneumatic dilation is typically used if a patient is not a candidate for POEM or the patient prefers dilation over POEM. Although patients often require multiple dilations with progressively larger balloons, it serves as an option for treatment of achalasia.

May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Pneumatic Dilation for Achalasia

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