Current clinical approach to achalasia

Table 1 Manometric variants of achalasia

Standard Manometry

Vigorous achalasia (high amplitude esophageal body contractions)

A short segment of esophageal body aperistalsis

Retained complete deglutitive LES relaxation with aperistalsis

Intact transient LES relaxation with aperistalsis

High resolution manometry (patients with impaired EGJ relaxation)

Type I: Minimal esophageal pressurization

Type II: Esophageal pressurization > 30 mmHg

Type III: Esophageal spasm

LES: Lower esophageal sphincter; EGJ: Esophagogastroduodenoscopy.

Table 2 Predictors of treatment response in achalasia

Treatment option	Positive predictors	Negative predictors
Botulinum toxin injection	Vigorous achalasia	Initial LES pressure ≥ 50% of the upper limit of normal
	Older patients	Lack of clinical response or residual LES pressure ≥ 18 mmHg after initial botulinum toxin treatment
Pneumatic dilatation	Older patients	Male Gender
		Pulmonary symptoms
		Failed response to 1-2 initial dilations
		High initial LES pressure (> 15-30 mmHg)1
		Reduction of LES pressure < 50% after the first dilation
Myotomy	Younger patients (< 40 yr)	Severe preoperative dysphagia
		Lower preoperative LES pressures of < 30-35 mmHg1
		Esophageal body dilation (flask type or sigmoid esophagus)
		Preoperative endoscopic treatment (in some studies)

¹Pressure values show considerable inter-study variability, depending on techniques used by different authors. Therefore, the pressure values shown in the table only reflect estimates based on the available literature.