Table 4 Preferred treatments for achalasia subtypes and achalasia syndromes as defined by CC v3.0

From: Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Condition

Preferred treatment

Comment

CC v3.0 achalasia subtypes

Type I achalasia

PD, LHM, POEM

• All treatments efficacious

• Expect more reflux after POEM, especially in patients with hiatal hernia

Type II achalasia

PD

All treatments are highly efficacious, PD has least morbidity and lowest cost

Type III achalasia

POEM

Can calibrate the myotomy to the spastic segment

Achalasia syndromes beyond CC v3.0

Oesophagogastric junction outflow obstruction

• 1st choice: observation

• 2nd choice: calcium-channel blockers

• 3rd choice: botulinum toxin type A

• Many cases resolve spontaneously

• If achalasia therapies are applied, 1st choice PD, 2nd choice POEM

Absent contractility deemed to be achalasia

PD, LHM, POEM

Treat as type I achalasia

DES deemed to be achalasia

POEM

Treat as type III achalasia

Opioid effect

• 1st choice: discontinue opioid

• 2nd choice: botulinum toxin type A

• 3rd choice: PD

• 4th choice: POEM

Time course of reversal with opioid cessation is not known

Obstruction

• Conventional dilation

• Operative reversal if relevant

• Directed medical therapy ifrelevant

Many entities mimic achalasia, sometimes termed 'pseudoachalasia': eosinophilic oesophagitis, cancer, reflux stricture etc.

  1. Preferred treatments are proposed by the authors of this Consensus Statement on the basis of available data and expert opinion. See Table 1 for defining criteria. CC, Chicago Classification; DES, distal oesophageal spasm; LHM, laparoscopic Heller myotomy; PD, pneumatic dilation; POEM, per-oral endoscopic myotomy.
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