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Idiopathic achalasia is caused by a degeneration of the myenteric nerve plexus of the esophagus which causes a motility disorder. Strictly speaking, the diagnostic criteria are both a failure of relaxation of the lower esophageal sphincter, and absence of esophageal peristalsis. With the new high-resolution manometries, we are able to subdivide Achalasia into types I, II and III. This is what is known as the Chicago classification. To summarize, in type I Achalasia the esophageal body shows minimal contractility; in type II, there is no peristalsis but intermittent periods of compartmentalized esophageal pressurization; and in type III there are spastic contractions in the distal esophagus.
The treatment mainstay for achalasia is clear: reducing pressure in the lower esophageal sphincter. There are several options to do so, which include surgery, endoscopic balloon dilation, botox injection, medication, and more recently what has been called the Per-Oral Endoscopic Myotomy (POEM).
In this talk, we will focus on the details of the available treatments for idiopathic achalasia. We will also go into details about some recent high-quality studies. Finally, we will discuss which is the best treatment depending on the achalasia subtype.