Materiały źródłowe

• #1 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test. HRM leverages improved space-time resolution and a more intuitive description of contractile and pressure patterns to refine the classification of motor dysfunction that was originally described using conventional low-resolution pressure tracing manometry.

• #2 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  We recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] We suggest that classifying achalasia subtypes by the Chicago Classification may help inform both prognosis and treatment choice. […] The diagnosis of achalasia is thus clinically suspected in patients who present with the above-mentioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI). […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test. […] The main benefits of this classification are an improved accuracy, an ability to distinguish clinically relevant subtypes, and a higher level of reproducibility.

• #3 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/journal/view.html?uid=1875&vmd=Full&

  Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. […] The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. […] The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. […] High-resolution manometry (HRM) is the gold standard diagnostic tool in patients presenting with dysphagia and beholds relevant implications for classification and treatment. […] A proposed diagnostic algorithm of patients presenting with suspected achalasia is depicted in Figure 1. […] Endoscopy is not always decisive in diagnosing achalasia and may be undetected in up to two-thirds of patients.

• #4

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. […] Diagnosis of achalasia is thus clinically suspected in patients who present with the abovementioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI) (4).

• #5 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] Timed barium esophagram showing retained barium and bird beaking in the appropriate clinical presentation may be diagnostic of achalasia. Endoscopic signs of dilated esophagus with retained saliva and food with puckered and tight gastroesophageal junction to the passage of endoscope should raise clinical suspicion for achalasia. […] We recommend that patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy should be evaluated for achalasia.

• #6

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test (8). HRM leverages improved space-time resolution and a more intuitive description of contractile and pressure patterns to refine the classification of motor dysfunction that was originally described using conventional low-resolution pressure tracing manometry. […] Achalasia is now recognized to present with 3 distinct manometric subtypes. All 3 subtypes have impaired EGJ relaxation, but the distinguishing features are the pattern of esophageal pressurization and contraction.

• #7 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/view.html?uid=1875&vmd=Full

  Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. […] The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. […] The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. […] High-resolution manometry (HRM) is the gold standard diagnostic tool in patients presenting with dysphagia and beholds relevant implications for classification and treatment. […] A proposed diagnostic algorithm of patients presenting with suspected achalasia is depicted in Figure 1. […] Endoscopy is not always decisive in diagnosing achalasia and may be undetected in up to two-thirds of patients.

• #8 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  We recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] We suggest that classifying achalasia subtypes by the Chicago Classification may help inform both prognosis and treatment choice. […] The diagnosis of achalasia is thus clinically suspected in patients who present with the above-mentioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI). […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test. […] The main benefits of this classification are an improved accuracy, an ability to distinguish clinically relevant subtypes, and a higher level of reproducibility.

• #9 Achalasia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK519515/

  Achalasia is an esophageal smooth muscle motility disorder that occurs due to a failure of relaxation of the lower esophageal sphincter. This condition causes a functional obstruction at the gastroesophageal junction. […] The best first test for achalasia with the most sensitive test for achalasia is esophageal manometry. […] When there is clinical suspicion for achalasia, diagnostic studies to confirm the disease must take place as symptoms do not reliably diagnose achalasia. […] The best initial test to diagnose achalasia is a barium esophagogram (barium swallow). […] Upper endoscopy (esophagogastroduodenoscopy – EGD) is recommended in all patients with suspected achalasia or dysphagia to exclude premalignant or malignant lesions involving the esophagus. […] Esophageal manometry is the most sensitive test for the diagnosis of achalasia and remains the gold standard.

• #10 Achalasia – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/achalasia/diagnosis-treatment/drc-20352851

  Achalasia can be overlooked or misdiagnosed because it has symptoms similar to those of other digestive disorders. To test for achalasia, a healthcare professional is likely to recommend: […] Esophageal manometry. This test measures the muscle contractions in the esophagus during swallowing. It also measures how well the lower esophageal sphincter opens during a swallow. This test is the most helpful when deciding which type of swallowing condition you might have. […] Functional luminal imaging probe (FLIP) technology. FLIP is a new technique that can help confirm an achalasia diagnosis if other tests aren’t enough. […] A strong improvement from injection of Botox may help confirm a diagnosis of achalasia.

• #11 Achalasia

  https://elsevier.health/en-US/preview/achalasia-co

  Achalasia is a motor disorder of the esophagus characterized by aperistalsis and incomplete lower esophageal sphincter relaxation without evidence of mechanical obstruction. […] Diagnosis is established by esophageal manometry and may be supported by findings on barium esophagogram. […] All patients require esophagogastroduodenoscopy to exclude mechanical obstruction due to malignancy. […] Suspect diagnosis in patients with dysphagia to solids and liquids or with heartburn that does not resolve with an adequate trial of proton pump inhibitors. […] High-resolution manometry is preferred over conventional because it provides more information, is more comfortable for the patient, can simultaneously assess upper and lower esophageal sphincters and peristalsis, and allows achalasia to be classified into 3 specific clinical subtypes based on esophageal pressure topography.

• #12 Patient education: Achalasia (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/achalasia-beyond-the-basics

  Achalasia may be suspected based upon symptoms, but tests are needed to confirm the diagnosis. […] Chest X-rays — A chest X-ray may reveal a dilated esophagus and absence of air in the stomach. However, a chest X-ray is not adequate for a diagnosis of achalasia and further testing is required. […] Barium swallow test — The barium swallow test is a common screening test for achalasia. The test involves swallowing a chalky-tasting, thick mixture of barium while X-rays are taken. The barium shows the outline of the esophagus and lower esophageal sphincter (LES). Characteristic findings of achalasia on barium swallow include a persistently narrowed region at the end of the esophagus (the LES), with a dilated esophagus above the narrowed region. […] Esophageal manometry (also called esophageal motility study) — Manometry is a test that measures changes in pressures within the esophagus that are caused by the contraction of the muscles that line the esophagus. The test typically reveals three abnormalities in people with achalasia: high pressure in the LES at rest, failure of the LES to relax after swallowing, and an absence of useful (peristaltic) contractions in the lower esophagus.

• #13 Achalasia Workup: Approach Considerations, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/169974-workup

  A diagnosis of achalasia should be considered when a patient presents with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. […] The American College of Gastroenterology released new guidelines for the diagnosis and management of achalasia in September, 2020. Recommendations for the proper diagnosis of achalasia include the following: Evaluate patients with suspected GERD who do not respond to treatment for achalasia […] Symptomatic patients with suspected achalasia should undergo upper endoscopy to rule out pseudoachalasia and exclude other pathology. […] High resolution esophageal manometry is the criterion standard in helping to diagnose the classic findings of achalasia. These findings include the following: Incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing […] High resting LES pressure […] Absent esophageal peristalsis. […] Prolonged esophageal pH monitoring is important for the following reasons: To rule out gastroesophageal reflux disease (GERD) […] To determine if abnormal reflux is being caused by treatment.

• #14 Achalasia | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/achalasia?lang=us

  Achalasia is a failure of organized esophageal peristalsis that causes impaired relaxation of the lower esophageal sphincter, resulting in food stasis and often marked dilatation of the esophagus. […] The Chicago Classification v4.0 defines achalasia as 100% absent peristalsis on manometry (either failed peristalsis or premature contracture, depending on the subtype). […] The Eckhardt score can be used to grade the clinical severity of achalasia. […] Achalasia may be divided into three distinct subtypes based on manometric patterns per the Chicago Classification v4.0 (c. 2021): type I (classic achalasia): minimal contractility in the esophageal body, type II: intermittent periods of pan-esophageal pressurisation, type III (spastic achalasia): premature or spastic distal esophageal contractions.

• #15 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/journal/view.html?uid=1875&vmd=Full&

  The presence of a disorder of the outflow obstruction is confirmed by the presence of a persistently raised integrated relaxation pressure (IRP) at supine and upright swallows and on provocative tests at high-resolution manometry (HRM) study. […] The classification for esophageal motility disorders is the Chicago classification (CC) has recently been updated to its fourth iteration (CC v4.0). […] Based on this classification, the key manometric parameter, which is the expression of the adequacy of the EGJ relaxation, is the integrated relaxation pressure (IRP), a measure of the pressure gradient between the esophageal body and the proximal stomach measured during the window of relaxation of a swallow. […] If esophageal body peristalsis is absent or spastic, achalasia is diagnosed. […] The most common scoring system used to assess severity of the disease is the standardized Eckardt symptom score (ESS), which encapsulates the 4 main presenting symptoms described: dysphagia, regurgitation, chest pain, and weight loss.

• #16 New Trends and Concepts in Diagnosis and Treatment of Achalasia | Cirugía Española (English Edition)

  https://www.elsevier.es/en-revista-cirugia-espanola-english-edition–436-articulo-new-trends-concepts-in-diagnosis-S2173507713002056

  Esophageal manometry is the gold standard for the diagnosis of achalasia. Classical criteria for the diagnosis of achalasia include: impaired LES relaxation and the absence of peristalsis. Nevertheless, considerable heterogeneity has been documented with regard to peristaltic abnormalities and esophageal pressure dynamics in patients with esophageal achalasia. Pandolfino et al. have recently reported 3 manometric patterns of esophageal body contractility in achalasia that are quite distinct: (1) with minimum pressurization; (2) with esophageal compression, either located in the distal esophagus or in the entire length of the esophagus; and (3) compression attributable to spastic contractions. These authors found that patients with type II are much more likely to respond to treatment than type I or III. In a logistic regression analysis, type II was a predictor for positive response to treatment, while type III was a predictor for negative response to treatment.

• #17 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  We recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] We suggest that classifying achalasia subtypes by the Chicago Classification may help inform both prognosis and treatment choice. […] The diagnosis of achalasia is thus clinically suspected in patients who present with the above-mentioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI). […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test. […] The main benefits of this classification are an improved accuracy, an ability to distinguish clinically relevant subtypes, and a higher level of reproducibility.

• #18 Patient education: Achalasia (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/achalasia-beyond-the-basics

  Achalasia may be suspected based upon symptoms, but tests are needed to confirm the diagnosis. […] Chest X-rays — A chest X-ray may reveal a dilated esophagus and absence of air in the stomach. However, a chest X-ray is not adequate for a diagnosis of achalasia and further testing is required. […] Barium swallow test — The barium swallow test is a common screening test for achalasia. The test involves swallowing a chalky-tasting, thick mixture of barium while X-rays are taken. The barium shows the outline of the esophagus and lower esophageal sphincter (LES). Characteristic findings of achalasia on barium swallow include a persistently narrowed region at the end of the esophagus (the LES), with a dilated esophagus above the narrowed region. […] Esophageal manometry (also called esophageal motility study) — Manometry is a test that measures changes in pressures within the esophagus that are caused by the contraction of the muscles that line the esophagus. The test typically reveals three abnormalities in people with achalasia: high pressure in the LES at rest, failure of the LES to relax after swallowing, and an absence of useful (peristaltic) contractions in the lower esophagus.

• #19 Achalasia (Esophagus Disorder): Symptoms, Causes, Treatments

  https://my.clevelandclinic.org/health/diseases/17534-achalasia

  Achalasia is a rare disorder in which damaged nerves in your esophagus prevent it from working as it should. […] Achalasia is a rare disorder in which your esophagus is unable to move food and liquids down into your stomach. […] Achalasia develops in about 1 in every 100,000 people in the U.S. each year. […] Yes, it can be, especially if it goes untreated. […] If you have achalasia, the LES fails to relax and food and liquids cant pass through your esophagus into your stomach. […] Three tests are commonly used to diagnose achalasia: […] Barium swallow: For this test, youll swallow a barium preparation (liquid or other form) and its movement through your esophagus is evaluated using X-rays. […] Upper endoscopy: In this test, a flexible, narrow tube with a camera on it called an endoscope is passed down your esophagus.

• #20 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] Timed barium esophagram showing retained barium and bird beaking in the appropriate clinical presentation may be diagnostic of achalasia. Endoscopic signs of dilated esophagus with retained saliva and food with puckered and tight gastroesophageal junction to the passage of endoscope should raise clinical suspicion for achalasia. […] We recommend that patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy should be evaluated for achalasia.

• #21 Diagnosis of achalasia – Xiao – Journal of Xiangya Medicine

  https://jxym.amegroups.org/article/view/5080/html

  A typical appearance of barium esophagogram is birds beak in achalasia patients, this described the narrowing of the EGJ and dilation of the distal esophagus. […] As a noninvasive method, time barium esophagram (TBE) objectively quantifies esophageal emptying and also the morphology. […] Esophageal manometry has been recognized as the gold standard for the diagnosis of achalasia. […] The new criteria were named as Chicago classification where the first version of this classification was established. […] The diagnosis of achalasia should combine both clinical findings and auxiliary examination focused on structure and function.

• #22 Diagnosis and Management of Achalasia: Updates of the Last Two Years

  https://www.mdpi.com/2077-0383/10/16/3607

  Barium esophagography has commonly been used to evaluate esophageal morphology prior to surgery. […] Recently, the timed barium swallow (TBS) has been used to assess treatment success by evaluating esophageal emptying. […] Endoflip is a novel diagnostic device that permits measurement of the level of distensibility at the esophagogastric junction as well as is capable of detecting the various achalasia subtypes with a high level of confidence and accuracy. […] The most fundamental goals of treating achalasia are to attain symptomatic relief and to improve patients’ quality of life and work capability. […] The treatment choice of achalasia should be tailored, taking into account several clinical and manometric factors. […] Recent published data from retrospective, prospective, and randomized studies indicate that there is no superiority between the three options of pneumatic dilation, LHM, and POEM.

• #23 Achalasia

  https://elsevier.health/en-US/preview/achalasia-co

  Obtain high-resolution esophageal manometry to establish diagnosis in all patients with suspected disease who do not have evidence of a mechanical obstruction on esophagogastroduodenoscopy. […] Timed barium esophagogram is preferred over standard barium esophagography. […] The following findings support the diagnosis of achalasia: Narrow gastroesophageal junction with a bird-beak or corkscrew appearance, Aperistalsis, Retained food in esophagus, Delayed emptying of barium, Dilation of esophagus, Absence or diminution of gastric air bubbles. […] High-resolution manometry with esophageal pressure topography has replaced conventional manometry; this is the gold standard test for diagnosing achalasia. […] In the presence of suggestive symptoms, diagnosis is confirmed by the combination of aperistalsis and incomplete lower esophageal sphincter relaxation without evidence of mechanical obstruction.

• #24 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] Timed barium esophagram showing retained barium and bird beaking in the appropriate clinical presentation may be diagnostic of achalasia. Endoscopic signs of dilated esophagus with retained saliva and food with puckered and tight gastroesophageal junction to the passage of endoscope should raise clinical suspicion for achalasia. […] We recommend that patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy should be evaluated for achalasia.

• #25 Patient education: Achalasia (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/achalasia-beyond-the-basics

  Endoscopy — Endoscopy allows the physician to see the inside of the esophagus, LES, and stomach using a thin, lighted, flexible tube. In people with achalasia, endoscopy often reveals a dilated esophagus that contains retained food; it may also reveal inflammation, small ulcers caused by residual food or pills, and candida (yeast) infection.

• #26 Role of endoscopy in patients with achalasia

  https://www.e-ce.org/journal/view.php?number=7793

  Although HRM is the gold standard for the diagnosis of achalasia, endoscopy plays an important role in early evaluation, primarily to exclude other diseases such as webs, rings, esophageal cancer, and proximal gastric cancer, which can mimic the symptoms of achalasia. […] The classic endoscopic findings of achalasia include retained saliva with a puckered EGJ, widening of the esophageal lumen, and food residue in the esophagus. […] The descriptive rules for achalasia of the esophagus, established by the Japan Esophageal Society present the diagnostic features of achalasia on endoscopy as follows: (1) dilatation of the esophageal lumen; (2) abnormal retention of food and/or liquid remnants in the esophagus; (3) whitish change and thickening of the esophageal mucosal surface; (4) functional stenosis of the EGJ, in which the endoscope passes through the stenotic segment and the EGJ fails to dilate by insufflation; and (5) abnormal contraction waves of the esophagus.

• #27 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] Timed barium esophagram showing retained barium and bird beaking in the appropriate clinical presentation may be diagnostic of achalasia. Endoscopic signs of dilated esophagus with retained saliva and food with puckered and tight gastroesophageal junction to the passage of endoscope should raise clinical suspicion for achalasia. […] We recommend that patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy should be evaluated for achalasia.

• #28 Role of endoscopy in patients with achalasia

  https://www.e-ce.org/journal/view.php?number=7793

  Although HRM is the gold standard for the diagnosis of achalasia, endoscopy plays an important role in early evaluation, primarily to exclude other diseases such as webs, rings, esophageal cancer, and proximal gastric cancer, which can mimic the symptoms of achalasia. […] The classic endoscopic findings of achalasia include retained saliva with a puckered EGJ, widening of the esophageal lumen, and food residue in the esophagus. […] The descriptive rules for achalasia of the esophagus, established by the Japan Esophageal Society present the diagnostic features of achalasia on endoscopy as follows: (1) dilatation of the esophageal lumen; (2) abnormal retention of food and/or liquid remnants in the esophagus; (3) whitish change and thickening of the esophageal mucosal surface; (4) functional stenosis of the EGJ, in which the endoscope passes through the stenotic segment and the EGJ fails to dilate by insufflation; and (5) abnormal contraction waves of the esophagus.

• #29 Advances in the diagnosis and treatment of achalasia of the cardia: A review

  https://www.degruyterbrill.com/document/doi/10.2478/jtim-2021-0009/html?srsltid=AfmBOorQ67LW7AIG9iqTvJIBODUnzTpVAgm_O_rWZSfkHYsb6a3PS91r

  Studies have shown that both endoscopy and barium esophagography are less sensitive than manometry and only identify about half (or even less) of patients with early-stage AC. […] EUS is widely used in the diagnosis and treatment of digestive tract diseases, as it allows for a clear view of the layered structure and thickness of the esophageal wall. […] Esophageal emptying tests, such as the radionuclide esophageal transit study and the barium esophageal transit study, are primarily used to assess the transit and emptying of food in the esophagus, facilitating evaluation of the esophageal emptying function and assessment of treatment effects. […] The aim of pharmacological therapy is to alleviate esophageal obstruction through LES relaxation, thereby providing temporary symptomatic relief.

• #30

  https://link.springer.com/article/10.1007/s00268-022-06483-3

  A precise diagnosis is key to the successful treatment of achalasia. Barium swallow, upper endoscopy and high-resolution manometry provide the necessary information about a patients anatomy, absence of other diseases, and type of achalasia (I, II, III). High-resolution manometry also has prognostic value, the best results of treatment being obtained in type II achalasia according to the Chicago classification. Abdominal CT scanning and endoscopic ultrasound might be warranted if an underlying malignancy is suspected. […] The diagnosis of esophageal disorders relies basically on three well-established, and often complementary tests: upper endoscopy, barium esophagogram, and (high-resolution) manometry. […] All patients referred for dysphagia should first undergo esophagogastroduodenoscopy with mucosal biopsies to exclude other causes of dysphagia, such as erosive GERD, eosinophilic esophagitis, structural lesions (strictures, webs, or rings), and especially esophageal cancer or pseudoachalasia. Endoscopy is a fundamentally important test, but not very sensitive in establishing a diagnosis of achalasia because more than 40% of patients with achalasia have normal endoscopic findings.

• #31 Achalasia – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/achalasia/diagnosis-treatment/drc-20352851

  Achalasia can be overlooked or misdiagnosed because it has symptoms similar to those of other digestive disorders. To test for achalasia, a healthcare professional is likely to recommend: […] Esophageal manometry. This test measures the muscle contractions in the esophagus during swallowing. It also measures how well the lower esophageal sphincter opens during a swallow. This test is the most helpful when deciding which type of swallowing condition you might have. […] Functional luminal imaging probe (FLIP) technology. FLIP is a new technique that can help confirm an achalasia diagnosis if other tests aren’t enough. […] A strong improvement from injection of Botox may help confirm a diagnosis of achalasia.

• #32 Achalasia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia

  Functional lumen imaging probe (FLIP) is a high-resolution impedance system that assesses cross-sectional area and simultaneous pressure (distensibility). FLIP is useful in diagnosing achalasia and may help in equivocal cases where manometry fails to diagnose achalasia despite a high clinical suspicion. […] Achalasia must be differentiated from a peptic stricture, particularly in patients with systemic sclerosis, in whom esophageal manometry may also show aperistalsis. […] Symptoms similar to those of achalasia (ie, pseudoachalasia) may be due to cancer at the gastroesophageal junction, which can be diagnosed by CT of the chest and abdomen or by endoscopic ultrasound with biopsy. […] Esophageal manometry is the preferred test for achalasia and shows an elevated integrated relaxation pressure in conjunction with 100% failed peristalsis. […] Barium swallow shows absence of progressive peristaltic contractions during swallowing and a markedly dilated esophagus with beaklike narrowing at the LES.

• #33 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/journal/view.html?uid=1875&vmd=Full&

  Malignant or other benign esophageal disorders may mimic the initial presentation of esophageal achalasia. […] Further, recent evidence recognizes that EoE may also be associated with abnormal motor activity, some even exhibiting manometric patterns of achalasia and/or esophagogastric outflow obstruction (EGJOO). […] The presence and the severity of the obstruction should also be confirmed by additional diagnostic tests (functional luminal imaging probe [FLIP] and timed barium esophagogram [TBE]) prior to referring patients to treatment. […] In recent years, additional diagnostic tests have demonstrated relevant diagnostic and prognostic value in the assessment of achalasia, particularly when the results at HRM are dubious and/or inconclusive. […] The functional lumen imaging probe (FLIP) is a novel complementary test that offers a valuable aid in diagnosing achalasia and EGJOO, particularly when HRM findings are inconclusive.

• #34

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Based on the inherent benefit of improved detail in describing esophageal pressurization and contractile patterns using esophageal pressure topography and superior accuracy and reproducibility in diagnosing achalasia in both randomized controlled and blinded comparison studies, we recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] The functional lumen imaging probe (FLIP) is a high-resolution impedance system that is approved by the U.S. Food and Drug Administration to study the pressure geometry relationship and motor function of the esophagus. Its role in the diagnosis of achalasia and post-therapy assessment of patients is evolving. […] Based on consistent but low-quality data, the role of FLIP in achalasia is evolving, and it may be helpful in patients who cannot tolerate manometry and also may function as an arbiter in difficult cases before and after treatment.

• #35 Achalasia Diagnosis | Stanford Health Care

  https://stanfordhealthcare.org/medical-conditions/digestion-and-metabolic-health/achalasia/diagnosis.html

  EndoFlip: This test measures the diameter of the esophagus and how wide it can stretch. EndoFlip can be useful in confirming a diagnosis of achalasia when other diagnostic tests have been inconclusive. […] Upper endoscopy: Using an endoscope, we carefully examine the lining of the esophagus for ulcers, inflammation, infection, and cancer. We may also take a tissue sample (biopsy) and examine it under a microscope.

• #36 Achalasia | Children’s Hospital of Philadelphia

  https://www.chop.edu/conditions-diseases/achalasia

  Children with symptoms commonly seen in esophageal achalasia may require an esophagogastroduodenoscopy (EGD), commonly called an endoscopy. […] Currently, EndoFLIP technology is being tested as a potential diagnostic test for achalasia. […] Esophageal manometry is the gold standard diagnostic test in diagnosing achalasia and reveals the lack of esophageal motility and impaired relaxation of the LES. […] The EndoFLIP allows the physician to visualize any narrowing at the moment of the study and decide if the area requires dilation.

• #37 Achalasia Workup: Approach Considerations, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/169974-workup

  A diagnosis of achalasia should be considered when a patient presents with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. […] The American College of Gastroenterology released new guidelines for the diagnosis and management of achalasia in September, 2020. Recommendations for the proper diagnosis of achalasia include the following: Evaluate patients with suspected GERD who do not respond to treatment for achalasia […] Symptomatic patients with suspected achalasia should undergo upper endoscopy to rule out pseudoachalasia and exclude other pathology. […] High resolution esophageal manometry is the criterion standard in helping to diagnose the classic findings of achalasia. These findings include the following: Incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing […] High resting LES pressure […] Absent esophageal peristalsis. […] Prolonged esophageal pH monitoring is important for the following reasons: To rule out gastroesophageal reflux disease (GERD) […] To determine if abnormal reflux is being caused by treatment.

• #38 Achalasia: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/169974-overview

  Achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing. The LES is hypertensive in about 50% of patients. These abnormalities cause a functional obstruction at the gastroesophageal junction (GEJ). […] Laboratory studies are noncontributory. Studies that may be helpful include the following: Barium swallow: Birds beak appearance, esophageal dilatation. Esophageal manometry (the criterion standard): Incomplete LES relaxation in response to swallowing, high resting LES pressure, absent esophageal peristalsis; classify achalasia subtypes by the Chicago Classification to help inform prognosis and treatment plan. Prolonged esophageal pH monitoring to rule out gastroesophageal reflux disease and determine if abnormal reflux is being caused by treatment. Esophagogastroduodenoscopy to rule out cancer of the GEJ or fundus. Concomitant endoscopic ultrasonography if a tumor is suspected.

• #39 Patient education: Achalasia (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/achalasia-beyond-the-basics

  Achalasia may be suspected based upon symptoms, but tests are needed to confirm the diagnosis. […] Chest X-rays — A chest X-ray may reveal a dilated esophagus and absence of air in the stomach. However, a chest X-ray is not adequate for a diagnosis of achalasia and further testing is required. […] Barium swallow test — The barium swallow test is a common screening test for achalasia. The test involves swallowing a chalky-tasting, thick mixture of barium while X-rays are taken. The barium shows the outline of the esophagus and lower esophageal sphincter (LES). Characteristic findings of achalasia on barium swallow include a persistently narrowed region at the end of the esophagus (the LES), with a dilated esophagus above the narrowed region. […] Esophageal manometry (also called esophageal motility study) — Manometry is a test that measures changes in pressures within the esophagus that are caused by the contraction of the muscles that line the esophagus. The test typically reveals three abnormalities in people with achalasia: high pressure in the LES at rest, failure of the LES to relax after swallowing, and an absence of useful (peristaltic) contractions in the lower esophagus.

• #40 Achalasia Workup: Approach Considerations, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/169974-workup

  A diagnosis of achalasia should be considered when a patient presents with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. […] The American College of Gastroenterology released new guidelines for the diagnosis and management of achalasia in September, 2020. Recommendations for the proper diagnosis of achalasia include the following: Evaluate patients with suspected GERD who do not respond to treatment for achalasia […] Symptomatic patients with suspected achalasia should undergo upper endoscopy to rule out pseudoachalasia and exclude other pathology. […] High resolution esophageal manometry is the criterion standard in helping to diagnose the classic findings of achalasia. These findings include the following: Incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing […] High resting LES pressure […] Absent esophageal peristalsis. […] Prolonged esophageal pH monitoring is important for the following reasons: To rule out gastroesophageal reflux disease (GERD) […] To determine if abnormal reflux is being caused by treatment.

• #41 Achalasia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia

  Functional lumen imaging probe (FLIP) is a high-resolution impedance system that assesses cross-sectional area and simultaneous pressure (distensibility). FLIP is useful in diagnosing achalasia and may help in equivocal cases where manometry fails to diagnose achalasia despite a high clinical suspicion. […] Achalasia must be differentiated from a peptic stricture, particularly in patients with systemic sclerosis, in whom esophageal manometry may also show aperistalsis. […] Symptoms similar to those of achalasia (ie, pseudoachalasia) may be due to cancer at the gastroesophageal junction, which can be diagnosed by CT of the chest and abdomen or by endoscopic ultrasound with biopsy. […] Esophageal manometry is the preferred test for achalasia and shows an elevated integrated relaxation pressure in conjunction with 100% failed peristalsis. […] Barium swallow shows absence of progressive peristaltic contractions during swallowing and a markedly dilated esophagus with beaklike narrowing at the LES.

• #42

  https://link.springer.com/article/10.1007/s00268-022-06483-3

  The aim of barium swallow is to study the capacity for emptying and morphology of the gullet. The diagnostic sensitivity of barium swallow for achalasia is 60%, while in the remaining 40% of cases the findings are normal or they suggest other disorders. […] High-resolution esophageal manometry is the gold standard for diagnosing achalasia, based on a lack of peristalsis and an impaired or absent relaxation of the LES in response to swallowing. […] The functional lumen imaging probe (FLIP) is a new technology that delivers real-time, simultaneous measurements of the pressure and diameter of the esophagus in a simulated 3D model. […] CT scanning can have an important role in this context, however, because esophageal narrowing is a common finding on CT scans in both primary achalasia and pseudoachalasia, but the narrowed segment tends to be smooth in patients with the former and uneven in those with the latter. […] Another useful test for distinguishing between primary achalasia and pseudoachalasia is endoscopic ultrasonography.

• #43 Achalasia – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/achalasia/diagnosis-treatment/drc-20352851

  Achalasia can be overlooked or misdiagnosed because it has symptoms similar to those of other digestive disorders. To test for achalasia, a healthcare professional is likely to recommend: […] Esophageal manometry. This test measures the muscle contractions in the esophagus during swallowing. It also measures how well the lower esophageal sphincter opens during a swallow. This test is the most helpful when deciding which type of swallowing condition you might have. […] Functional luminal imaging probe (FLIP) technology. FLIP is a new technique that can help confirm an achalasia diagnosis if other tests aren’t enough. […] A strong improvement from injection of Botox may help confirm a diagnosis of achalasia.

• #44 Achalasia: Diagnosis and Management

  https://scholarlycommons.libraryinfo.bhs.org/all_works/11169/

  Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. […] Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. […] Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.

• #45 The Pathogenesis and Management of Achalasia: Current Status and Future Directions

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl14446

  The diagnosis of idiopathic achalasia is relatively straightforward with a well-documented medical history, radiography, and esophageal motility testing. In the early stages of the disease, dysphagia may be very subtle and can be misinterpreted as dyspepsia, poor gastric emptying, or stress. The presence of heartburn due to food stasis can add to this confusion. As the disease progresses, difficulty swallowing characteristically occurs with both solid foods, and liquids. The dysphagia is more to solids than liquids. To ease progression of the food bolus, patients usually modify their eating habits: eating more slowly or use certain maneuvers such as raising the arms, or arching the back. The most common misdiagnosis of achalasia is GERD since many patients regurgitation symptom is misinterpreted as reflux disease. It is important to ask about dysphagia or hanging up symptoms and be alert to the possible achalasia diagnosis in those who are not improved on PPI therapy post initial suspicion of GERD. […]

• #46 The Pathogenesis and Management of Achalasia: Current Status and Future Directions

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl14446

  The diagnosis of achalasia is supported by esophagram findings including dilation of the esophagus, a narrow esophagogastric junction (EGJ) with bird beak appearance, aperistalsis, and poor emptying of barium. It may also be helpful in cases where esophageal manometry may be associated with equivocal findings. In addition to supporting the diagnosis of achalasia, an esophagram is also useful to assess for late- or end-stage achalasia changes (tortuosity, angulation, megaesophagus) that have implications for treatment. […] […] The primary role of EGD in the workup of achalasia is focused on ruling out a mechanical obstruction or pseudoachalasia as they can mimic achalasia both clinically and manometrically. Similar to the manometric features in achalasia, mechanical obstruction can result in both impaired EGJ relaxation and abnormal esophageal body function (aperistalsis or spastic contractions). Clinical presentation of dysphagia to solids and liquids in association with older age, weight loss, and a short duration of symptoms may clinically be suggestive of an infiltrating cancer; however, they are not sensitive or specific. Thus, patients presenting with a motor pattern or esophagram consistent with achalasia should be referred for endoscopic assessment with careful evaluation of the EGJ and gastric cardia on retroflexed view to rule out an infiltrating cancer. […]

• #47

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. […] Diagnosis of achalasia is thus clinically suspected in patients who present with the abovementioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI) (4).

• #48 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/journal/view.html?uid=1875&vmd=Full&

  Malignant or other benign esophageal disorders may mimic the initial presentation of esophageal achalasia. […] Further, recent evidence recognizes that EoE may also be associated with abnormal motor activity, some even exhibiting manometric patterns of achalasia and/or esophagogastric outflow obstruction (EGJOO). […] The presence and the severity of the obstruction should also be confirmed by additional diagnostic tests (functional luminal imaging probe [FLIP] and timed barium esophagogram [TBE]) prior to referring patients to treatment. […] In recent years, additional diagnostic tests have demonstrated relevant diagnostic and prognostic value in the assessment of achalasia, particularly when the results at HRM are dubious and/or inconclusive. […] The functional lumen imaging probe (FLIP) is a novel complementary test that offers a valuable aid in diagnosing achalasia and EGJOO, particularly when HRM findings are inconclusive.

• #49 Achalasia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/achalasia

  Functional lumen imaging probe (FLIP) is a high-resolution impedance system that assesses cross-sectional area and simultaneous pressure (distensibility). FLIP is useful in diagnosing achalasia and may help in equivocal cases where manometry fails to diagnose achalasia despite a high clinical suspicion. […] Achalasia must be differentiated from a peptic stricture, particularly in patients with systemic sclerosis, in whom esophageal manometry may also show aperistalsis. […] Symptoms similar to those of achalasia (ie, pseudoachalasia) may be due to cancer at the gastroesophageal junction, which can be diagnosed by CT of the chest and abdomen or by endoscopic ultrasound with biopsy. […] Esophageal manometry is the preferred test for achalasia and shows an elevated integrated relaxation pressure in conjunction with 100% failed peristalsis. […] Barium swallow shows absence of progressive peristaltic contractions during swallowing and a markedly dilated esophagus with beaklike narrowing at the LES.

• #50 Achalasia: Diagnosis and Management

  https://scholarlycommons.libraryinfo.bhs.org/all_works/11169/

  Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. […] Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. […] Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.

• #51 Achalasia – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/achalasia/

  Achalasia is a condition characterized by impaired relaxation of the lower esophageal sphincter (LES) due to degeneration of inhibitory neurons within the esophageal wall. High-resolution esophageal manometry is the preferred test to confirm the diagnosis. Upper endoscopy is indicated for all patients to rule out pseudoachalasia, which manifests similarly to achalasia but is caused by another underlying condition (e.g., malignancy). Barium esophagram is often obtained to support the diagnosis and/or assess treatment outcomes in patients with persistent or recurrent symptoms. […] Consider achalasia in patients with clinical features of achalasia and a suspected diagnosis of GERD unresponsive to PPI treatment. Obtain upper endoscopy to rule out pseudoachalasia. Obtain high-resolution esophageal manometry to confirm the diagnosis and classify subtype. Consider barium esophagram to confirm the diagnosis if manometry is inconclusive.

• #52 The Pathogenesis and Management of Achalasia: Current Status and Future Directions

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl14446

  The diagnosis of achalasia is supported by esophagram findings including dilation of the esophagus, a narrow esophagogastric junction (EGJ) with bird beak appearance, aperistalsis, and poor emptying of barium. It may also be helpful in cases where esophageal manometry may be associated with equivocal findings. In addition to supporting the diagnosis of achalasia, an esophagram is also useful to assess for late- or end-stage achalasia changes (tortuosity, angulation, megaesophagus) that have implications for treatment. […] […] The primary role of EGD in the workup of achalasia is focused on ruling out a mechanical obstruction or pseudoachalasia as they can mimic achalasia both clinically and manometrically. Similar to the manometric features in achalasia, mechanical obstruction can result in both impaired EGJ relaxation and abnormal esophageal body function (aperistalsis or spastic contractions). Clinical presentation of dysphagia to solids and liquids in association with older age, weight loss, and a short duration of symptoms may clinically be suggestive of an infiltrating cancer; however, they are not sensitive or specific. Thus, patients presenting with a motor pattern or esophagram consistent with achalasia should be referred for endoscopic assessment with careful evaluation of the EGJ and gastric cardia on retroflexed view to rule out an infiltrating cancer. […]

• #53 Achalasia – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/achalasia/

  Achalasia is a condition characterized by impaired relaxation of the lower esophageal sphincter (LES) due to degeneration of inhibitory neurons within the esophageal wall. High-resolution esophageal manometry is the preferred test to confirm the diagnosis. Upper endoscopy is indicated for all patients to rule out pseudoachalasia, which manifests similarly to achalasia but is caused by another underlying condition (e.g., malignancy). Barium esophagram is often obtained to support the diagnosis and/or assess treatment outcomes in patients with persistent or recurrent symptoms. […] Consider achalasia in patients with clinical features of achalasia and a suspected diagnosis of GERD unresponsive to PPI treatment. Obtain upper endoscopy to rule out pseudoachalasia. Obtain high-resolution esophageal manometry to confirm the diagnosis and classify subtype. Consider barium esophagram to confirm the diagnosis if manometry is inconclusive.

• #54 Diagnosis and Management of Achalasia

  https://www.mdcalc.com/guidelines/505/acg/diagnosis-management-achalasia

  Must suspect achalasia if dysphagia to solids and liquids and if regurgitation unresponsive to PPI trial (prevalence = 10 in 100,000). […] All patients with suspected achalasia without mechanical obstruction on endoscopy or esophagram should undergo esophageal motility testing to confirm diagnosis. […] Achalasia diagnosis is supported by dilated esophagus, narrow esophagogastric junction with bird beak appearance, aperistalsis, incomplete lower esophageal sphincter relaxation, poor emptying of barium on esophagram. […] If motility testing equivocal, barium esophagram recommended to assess esophageal emptying and esophagogastric junction. […] Endoscopy to assess gastroesophageal junction and cardia is recommended in all achalasia patients to rule out pseudoachalasia.

• #55 Achalasia Workup: Approach Considerations, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/169974-workup

  A diagnosis of achalasia should be considered when a patient presents with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. […] The American College of Gastroenterology released new guidelines for the diagnosis and management of achalasia in September, 2020. Recommendations for the proper diagnosis of achalasia include the following: Evaluate patients with suspected GERD who do not respond to treatment for achalasia […] Symptomatic patients with suspected achalasia should undergo upper endoscopy to rule out pseudoachalasia and exclude other pathology. […] High resolution esophageal manometry is the criterion standard in helping to diagnose the classic findings of achalasia. These findings include the following: Incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing […] High resting LES pressure […] Absent esophageal peristalsis. […] Prolonged esophageal pH monitoring is important for the following reasons: To rule out gastroesophageal reflux disease (GERD) […] To determine if abnormal reflux is being caused by treatment.

• #56 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  We recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] We suggest that classifying achalasia subtypes by the Chicago Classification may help inform both prognosis and treatment choice. […] The diagnosis of achalasia is thus clinically suspected in patients who present with the above-mentioned classic symptoms and then confirmed by objective diagnostic tests discussed below. However, because heartburn may be present in 27%42% of patients with achalasia, patients are frequently initially misdiagnosed as having gastroesophageal reflux disease (GERD) and are treated with proton pump inhibitors (PPI). […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test. […] The main benefits of this classification are an improved accuracy, an ability to distinguish clinically relevant subtypes, and a higher level of reproducibility.

• #57

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] The diagnosis of achalasia is confirmed with high-resolution manometry (HRM), which is the current gold standard test (8). HRM leverages improved space-time resolution and a more intuitive description of contractile and pressure patterns to refine the classification of motor dysfunction that was originally described using conventional low-resolution pressure tracing manometry. […] Achalasia is now recognized to present with 3 distinct manometric subtypes. All 3 subtypes have impaired EGJ relaxation, but the distinguishing features are the pattern of esophageal pressurization and contraction.

• #58 Diagnosis and Management of Achalasia: Updates of the Last Two Years

  https://www.mdpi.com/2077-0383/10/16/3607

  After the exclusion of anatomical, structural, and inflammatory conditions, HRM study is necessary to assess the esophageal motor function and the relaxation of the lower sphincter. […] High-resolution manometry (HRM) is the most accurate investigative system ordinarily utilized in order to study esophageal motility and the LES function when evaluating upper gastrointestinal symptoms including dysphagia when endoscopic and radiologic modalities do not elucidate their cause. […] The Chicago classification, currently in its fourth version (CCv4.0), is a conceptualized and standardized approach to interpreting HRM findings. […] Since the introduction of the Chicago classification, three subtypes of achalasia could be identified, depending on the esophageal peristalsis failure type. […] This subtyping has improved our understanding of achalasia and, furthermore, has influenced the management plan, enabling a more personalized therapeutic approach.

• #59 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/view.html?uid=1875&vmd=Full

  Current treatment options are mostly directed at disrupting the EGJ, but there is no superior treatment. […] According to the American College of Gastroenterology clinical guidelines, endoscopic pneumatic dilatation (PD) is an effective non-surgical treatment option for patients with achalasia. […] The laparoscopic Heller myotomy (LHM) is a surgical myotomy of the LES muscle fibers without disruption of the mucosa that can be performed laparoscopically, and most recently with robotic surgery techniques. […] POEM has been demonstrated to be effective in treating all achalasia subtypes, but is superior to LHM in treating type III achalasia, likely reflecting the longer myotomy obtained with POEM as compared to LHM. […] In older patients who are unfit for surgery or endoscopic treatment with poor performance status, Botulinum toxin injection is a safe procedure with low rates of complications. […] Over the last 2 decades, investigation, definition and treatment options for achalasia have advanced markedly.

• #60 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/view.html?uid=1875&vmd=Full

  Current treatment options are mostly directed at disrupting the EGJ, but there is no superior treatment. […] According to the American College of Gastroenterology clinical guidelines, endoscopic pneumatic dilatation (PD) is an effective non-surgical treatment option for patients with achalasia. […] The laparoscopic Heller myotomy (LHM) is a surgical myotomy of the LES muscle fibers without disruption of the mucosa that can be performed laparoscopically, and most recently with robotic surgery techniques. […] POEM has been demonstrated to be effective in treating all achalasia subtypes, but is superior to LHM in treating type III achalasia, likely reflecting the longer myotomy obtained with POEM as compared to LHM. […] In older patients who are unfit for surgery or endoscopic treatment with poor performance status, Botulinum toxin injection is a safe procedure with low rates of complications. […] Over the last 2 decades, investigation, definition and treatment options for achalasia have advanced markedly.

• #61 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/journal/view.html?uid=1875&vmd=Full&

  The presence of a disorder of the outflow obstruction is confirmed by the presence of a persistently raised integrated relaxation pressure (IRP) at supine and upright swallows and on provocative tests at high-resolution manometry (HRM) study. […] The classification for esophageal motility disorders is the Chicago classification (CC) has recently been updated to its fourth iteration (CC v4.0). […] Based on this classification, the key manometric parameter, which is the expression of the adequacy of the EGJ relaxation, is the integrated relaxation pressure (IRP), a measure of the pressure gradient between the esophageal body and the proximal stomach measured during the window of relaxation of a swallow. […] If esophageal body peristalsis is absent or spastic, achalasia is diagnosed. […] The most common scoring system used to assess severity of the disease is the standardized Eckardt symptom score (ESS), which encapsulates the 4 main presenting symptoms described: dysphagia, regurgitation, chest pain, and weight loss.

• #62 Achalasia | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/achalasia?lang=us

  Achalasia is a failure of organized esophageal peristalsis that causes impaired relaxation of the lower esophageal sphincter, resulting in food stasis and often marked dilatation of the esophagus. […] The Chicago Classification v4.0 defines achalasia as 100% absent peristalsis on manometry (either failed peristalsis or premature contracture, depending on the subtype). […] The Eckhardt score can be used to grade the clinical severity of achalasia. […] Achalasia may be divided into three distinct subtypes based on manometric patterns per the Chicago Classification v4.0 (c. 2021): type I (classic achalasia): minimal contractility in the esophageal body, type II: intermittent periods of pan-esophageal pressurisation, type III (spastic achalasia): premature or spastic distal esophageal contractions.

• #63 Achalasia – Esophageal Health | UCLA Health

  https://www.uclahealth.org/medical-services/gastro/esophageal-health/diseases-we-treat/achalasia

  POEM has a special advantage in cases of prior Heller myotomy. […] POEM appears to be equivalent or slightly better than traditional Heller myotomy for type I and II achalasia. […] It is estimated that adverse events happen in less than 1-2% of patients undergoing POEM. […] The major new symptom after any myotomy, including POEM, is potential reflux (GERD, gastroesophageal reflux disease). […] After your doctor has diagnosed achalasia and determined that you are eligible for POEM, a preoperative evaluation may be recommended. […] A few months after your procedure, the post-procedural evaluation will start with pH testing to determine if you have acid reflux. […] Current studies of POEM for achalasia have indicated a 90% favorable response with normalization or near normalization of swallowing symptoms (post-POEM Eckardt scores typically are 0-1).

• #64 Achalasia (Esophagus Disorder): Symptoms, Causes, Treatments

  https://my.clevelandclinic.org/health/diseases/17534-achalasia

  Long-term follow-up is needed regardless of which treatment you receive. […] Balloon dilation improves symptoms in 50% to 93% of people with achalasia. […] Minimally invasive surgery/laparoscopic Heller myotomy is effective in 76% to 100% of people with achalasia. […] Botox injection successfully relaxes spastic esophageal sphincter muscles in up to 35% of people with achalasia. […] First, youll need to understand that achalasia is a lifelong condition.

• #65 Achalasia – Esophageal Health | UCLA Health

  https://www.uclahealth.org/medical-services/gastro/esophageal-health/diseases-we-treat/achalasia

  POEM has a special advantage in cases of prior Heller myotomy. […] POEM appears to be equivalent or slightly better than traditional Heller myotomy for type I and II achalasia. […] It is estimated that adverse events happen in less than 1-2% of patients undergoing POEM. […] The major new symptom after any myotomy, including POEM, is potential reflux (GERD, gastroesophageal reflux disease). […] After your doctor has diagnosed achalasia and determined that you are eligible for POEM, a preoperative evaluation may be recommended. […] A few months after your procedure, the post-procedural evaluation will start with pH testing to determine if you have acid reflux. […] Current studies of POEM for achalasia have indicated a 90% favorable response with normalization or near normalization of swallowing symptoms (post-POEM Eckardt scores typically are 0-1).

• #66 Achalasia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK519515/

  The use of conventional manometry has mostly given way to high-resolution manometry (HRM), which also includes pressure topography plotting. […] The recommended step for reducing pressure across the lower esophageal sphincter is surgical myotomy, which can be done laparoscopically. […] Pneumatic dilatation of the esophagus via endoscopy is the most cost-effective non-surgical therapy for achalasia. […] All patients who undergo treatment for achalasia need long-term follow-up because all available treatments are palliative, making recurrences common.

• #67 Achalasia

  https://elsevier.health/en-US/preview/achalasia-co

  Achalasia is considered a chronic incurable disorder; treatments aimed at reducing hypertonicity of lower esophageal sphincter are generally effective but do not represent a permanent cure. […] Approximately 10% to 15% of patients will progress to megaesophagus or end-stage achalasia despite treatment.

• #68 Diagnosis and Management of Achalasia: Updates of the Last Two Years

  https://www.mdpi.com/2077-0383/10/16/3607

  The introduction of the HRM with impedance along with the construction of the Chicago classification and their implementation in clinical practice has profoundly enriched our understanding of the esophageal and LES functions and has eventually led to classifying achalasia into three different types based on diverse manometric patterns.

• #69 Diagnosis and management of esophageal achalasia | The BMJ

  https://www.bmj.com/content/354/bmj.i2785

  Achalasia is a rare esophageal motility disorder that is usually idiopathic in origin. It is characterized by dysphagia, and patients often have chest pain, regurgitation, weight loss, and an abnormal barium radiograph showing esophageal dilation with narrowing at the gastroesophageal junction. Abnormal or absent esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES) are typically seen on esophageal manometry. The advent of high resolution manometry (HRM) has allowed more precise diagnosis of achalasia, subtype designation, and differentiation from other esophageal motor disorders with an initial seminal publication in 2008 followed by further refinements of what has been termed the Chicago classification. […] This review discusses the diagnosis and management of achalasia with particular emphasis on the recent developments of HRM and POEM, which arguably represent the most important advances in the field since the advent of laparoscopic Heller myotomy in the 1990s.

• #70

  https://journals.lww.com/ajg/fulltext/2020/09000/acg_clinical_guidelines__diagnosis_and_management.18.aspx

  Based on the inherent benefit of improved detail in describing esophageal pressurization and contractile patterns using esophageal pressure topography and superior accuracy and reproducibility in diagnosing achalasia in both randomized controlled and blinded comparison studies, we recommend using esophageal pressure topography over conventional line tracing for the diagnosis of achalasia. […] The functional lumen imaging probe (FLIP) is a high-resolution impedance system that is approved by the U.S. Food and Drug Administration to study the pressure geometry relationship and motor function of the esophagus. Its role in the diagnosis of achalasia and post-therapy assessment of patients is evolving. […] Based on consistent but low-quality data, the role of FLIP in achalasia is evolving, and it may be helpful in patients who cannot tolerate manometry and also may function as an arbiter in difficult cases before and after treatment.

• #71 Achalasia Diagnosis | Stanford Health Care

  https://stanfordhealthcare.org/medical-conditions/digestion-and-metabolic-health/achalasia/diagnosis.html

  EndoFlip: This test measures the diameter of the esophagus and how wide it can stretch. EndoFlip can be useful in confirming a diagnosis of achalasia when other diagnostic tests have been inconclusive. […] Upper endoscopy: Using an endoscope, we carefully examine the lining of the esophagus for ulcers, inflammation, infection, and cancer. We may also take a tissue sample (biopsy) and examine it under a microscope.

• #72 Diagnosis and Management of Achalasia: Updates of the Last Two Years

  https://www.mdpi.com/2077-0383/10/16/3607

  Barium esophagography has commonly been used to evaluate esophageal morphology prior to surgery. […] Recently, the timed barium swallow (TBS) has been used to assess treatment success by evaluating esophageal emptying. […] Endoflip is a novel diagnostic device that permits measurement of the level of distensibility at the esophagogastric junction as well as is capable of detecting the various achalasia subtypes with a high level of confidence and accuracy. […] The most fundamental goals of treating achalasia are to attain symptomatic relief and to improve patients’ quality of life and work capability. […] The treatment choice of achalasia should be tailored, taking into account several clinical and manometric factors. […] Recent published data from retrospective, prospective, and randomized studies indicate that there is no superiority between the three options of pneumatic dilation, LHM, and POEM.

• #73 Advances in the diagnosis and treatment of achalasia of the cardia: A review

  https://www.degruyterbrill.com/document/doi/10.2478/jtim-2021-0009/html?srsltid=AfmBOorQ67LW7AIG9iqTvJIBODUnzTpVAgm_O_rWZSfkHYsb6a3PS91r

  The primary clinical manifestation of AC is dysphagia, with disease progression occurring in the majority of patients. […] At this point in time, examinations such as EUS and computed tomography (CT) should be performed to differentiate between AC and pseudoachalasia (pseudo AC), which is caused by malignancies of the esophagogastric junction (EGJ), such as carcinoma of the cardia. […] Regardless of the barium esophagography and endoscopy findings, esophageal manometry is currently regarded as the gold standard for the diagnosis of AC. […] Endoscopy is an essential method in the diagnosis of AC. All patients with suspected AC should undergo endoscopic examination to rule out pseudo AC, as well as esophageal anatomical lesions and neoplastic diseases, which manifest similar clinical symptoms and manometric results.

• #74 Modern Achalasia: Diagnosis, Classification, and Treatment

  https://www.jnmjournal.org/view.html?uid=1875&vmd=Full

  Current treatment options are mostly directed at disrupting the EGJ, but there is no superior treatment. […] According to the American College of Gastroenterology clinical guidelines, endoscopic pneumatic dilatation (PD) is an effective non-surgical treatment option for patients with achalasia. […] The laparoscopic Heller myotomy (LHM) is a surgical myotomy of the LES muscle fibers without disruption of the mucosa that can be performed laparoscopically, and most recently with robotic surgery techniques. […] POEM has been demonstrated to be effective in treating all achalasia subtypes, but is superior to LHM in treating type III achalasia, likely reflecting the longer myotomy obtained with POEM as compared to LHM. […] In older patients who are unfit for surgery or endoscopic treatment with poor performance status, Botulinum toxin injection is a safe procedure with low rates of complications. […] Over the last 2 decades, investigation, definition and treatment options for achalasia have advanced markedly.

• #75 Diagnosis and Management of Achalasia: Updates of the Last Two Years

  https://www.mdpi.com/2077-0383/10/16/3607

  The introduction of the HRM with impedance along with the construction of the Chicago classification and their implementation in clinical practice has profoundly enriched our understanding of the esophageal and LES functions and has eventually led to classifying achalasia into three different types based on diverse manometric patterns.

• #76 ACG Clinical Guidelines: Diagnosis and Management of Achalasia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9896940/

  Endoscopy, barium esophagram, and esophageal manometry are 3 well established and often complementary tests in establishing the diagnosis of achalasia. Endoscopic findings of retained saliva with a puckered gastroesophageal junction or barium swallow showing a dilated esophagus with bird beaking are important diagnostic clues. […] Timed barium esophagram showing retained barium and bird beaking in the appropriate clinical presentation may be diagnostic of achalasia. Endoscopic signs of dilated esophagus with retained saliva and food with puckered and tight gastroesophageal junction to the passage of endoscope should raise clinical suspicion for achalasia. […] We recommend that patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy should be evaluated for achalasia.

• #77 The Pathogenesis and Management of Achalasia: Current Status and Future Directions

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl14446

  By definition, an assessment of esophageal motor function is essential in the diagnosis of achalasia. Barium esophagram and esophagogastroduodenoscopy (EGD) are complementary tests to manometry in the diagnosis and management of achalasia. However, neither EGD nor barium esophagram alone is sensitive enough to make the diagnosis of achalasia with certainty. EGD may be supportive of a diagnosis of achalasia in only one-third of patients, whereas esophagram may be nondiagnostic in up to one-third of patients. Thus, normal findings on EGD or esophagram in patients suspected of having achalasia should prompt esophageal motility testing. However, in patients with classic endoscopic and/or esophagram findings, esophageal motility would be considered supportive to confirm the diagnosis. […] […] The manometric finding of aperistalsis and incomplete LES relaxation without evidence of a mechanical obstruction solidifies the diagnosis of achalasia in the appropriate setting. Other findings, such as an increased basal LES pressure, an elevated baseline esophageal body pressure, and simultaneous nonpropagating contractions, may also support the diagnosis of achalasia, but these are not requirements for the diagnosis. […]

• #78 Achalasia – Esophageal Health | UCLA Health

  https://www.uclahealth.org/medical-services/gastro/esophageal-health/diseases-we-treat/achalasia

  POEM has a special advantage in cases of prior Heller myotomy. […] POEM appears to be equivalent or slightly better than traditional Heller myotomy for type I and II achalasia. […] It is estimated that adverse events happen in less than 1-2% of patients undergoing POEM. […] The major new symptom after any myotomy, including POEM, is potential reflux (GERD, gastroesophageal reflux disease). […] After your doctor has diagnosed achalasia and determined that you are eligible for POEM, a preoperative evaluation may be recommended. […] A few months after your procedure, the post-procedural evaluation will start with pH testing to determine if you have acid reflux. […] Current studies of POEM for achalasia have indicated a 90% favorable response with normalization or near normalization of swallowing symptoms (post-POEM Eckardt scores typically are 0-1).

• #79 Achalasia

  https://elsevier.health/en-US/preview/achalasia-co

  Achalasia is considered a chronic incurable disorder; treatments aimed at reducing hypertonicity of lower esophageal sphincter are generally effective but do not represent a permanent cure. […] Approximately 10% to 15% of patients will progress to megaesophagus or end-stage achalasia despite treatment.

• #80 Achalasia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK519515/

  The use of conventional manometry has mostly given way to high-resolution manometry (HRM), which also includes pressure topography plotting. […] The recommended step for reducing pressure across the lower esophageal sphincter is surgical myotomy, which can be done laparoscopically. […] Pneumatic dilatation of the esophagus via endoscopy is the most cost-effective non-surgical therapy for achalasia. […] All patients who undergo treatment for achalasia need long-term follow-up because all available treatments are palliative, making recurrences common.

• #81 Achalasia (Esophagus Disorder): Symptoms, Causes, Treatments

  https://my.clevelandclinic.org/health/diseases/17534-achalasia

  Long-term follow-up is needed regardless of which treatment you receive. […] Balloon dilation improves symptoms in 50% to 93% of people with achalasia. […] Minimally invasive surgery/laparoscopic Heller myotomy is effective in 76% to 100% of people with achalasia. […] Botox injection successfully relaxes spastic esophageal sphincter muscles in up to 35% of people with achalasia. […] First, youll need to understand that achalasia is a lifelong condition.

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