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ACG issues guidelines for diagnosis, management of achalasia

The American College of Gastroenterology has released new guidelines for the diagnosis and treatment of achalasia in the August issue of The American Journal of Gastroenterology.

The guidelines were devised following a PubMed search for data published between 1970 and 2012, with conclusions reached according to best available evidence or expert opinion. Investigators graded evidence quality via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

The authors recommend suspicion of achalasia among patients with dysphagia to liquids and solids, as well as patient with regurgitation symptoms that have proven unresponsive to treatment with proton pump inhibitors. Esophageal motility testing should be performed in these patients, in the absence of signs of mechanical obstruction. Esophagus dilation, narrow esophagogastric junction, aperistalsis and poor barium emptying on esophagram are indicative of the condition.

Graded pneumatic dilation (PD) or laparoscopic surgical myotomy with partial fundoplication are the recommended methods of achalasia treatment, as long as participants are willing and able to receive surgery. These procedures should be performed in high-volume centers of excellence. Among patients who are not candidates for surgery, the guidelines call for botulinum toxin therapy. Pharmacologic therapy should be administered in patients that cannot undergo PD or myotomy and also fail botulinum toxin treatment.

“Surgical myotomy has shown excellent results in most patients and remains the surgery of choice, with more being done laparoscopically,” lead author Michael F. Vaezi, MD, PhD, MSc of Vanderbilt University Medical Center, said in a press release. “The benefit of adding a fundoplication was demonstrated in a double-blind randomized trial comparing myotomy with vs. without fundoplication. In this study, abnormal acid exposure on pH monitoring was found in 47% of patients without an antireflux procedure, and 9% in patients that had a posterior Dor fundoplication.”

Upon completion of therapy, the guidelines call for barium esophagram to assess esophageal emptying and symptom release, but not surveillance endoscopy to detect esophageal cancer.