ACG develops clinical guidelines for diagnosis, treatment of achalasia
The American College of Gastroenterology released clinical guidelines to diagnose and treat patients with achalasia.
“Achalasia is a rare diagnosis with only [20,000 to 40,000] affected patients in the United States. It occurs equally in men and women, with no racial predilection,” Michael F. Vaezi, MD, PhD, MSc, FACG, from the division of gastroenterology, hepatology, and nutrition, Vanderbilt University School of Medicine in Nashville, and colleagues wrote. “The peak incidence occurs between 30 and 60 years of age. Patients often present with progressive dysphagia to solids and liquids, heartburn, chest pain, regurgitation, and varying degrees of weight loss or nutritional deficiencies.”
The Grading of Recommendations Assessment, Development and Evaluation process was used to develop the guidelines.
The recommendations for achalasia include:
- Patients should be assessed for achalasia if they are initially suspected of having gastroesophageal reflux disease; however, do not respond to acid-suppressive therapy;
- Esophageal pressure topography should be used over conventional line tracing for the diagnosis of achalasia;
- Achalasia subtypes should be classified with Chicago Classification to help with prognosis and treatment choice;
- Botulinum toxin injection should be used as first-line therapy for patients with achalasia unfit for definitive therapies vs. less-effective pharmacological therapies. A botulinum toxin injection would not significantly impact performance and outcomes of myotomy;
- Dor or Toupet fundoplication should be used to control esophageal acid exposure in patients with achalasia undergoing surgical myotomy;
- Tailored per-oral endoscopic myotomy or laparoscopic Heller's myotomy should be used for type III achalasia;
- Esophagectomy should be used in surgically fit patients with mega esophagus who failed all other interventions;
- Heller myotomy should be considered before esophagectomy in patients who failed peritoneal dialysis and per-oral endoscopic myotomy;and,
- Routine endoscopy should not be used for surveillance of esophageal carcinoma in patients with achalasia.