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Clinical Review State of the Art Review

Diagnosis and management of esophageal achalasia

BMJ 2016; 354 doi: (Published 13 September 2016) Cite this as: BMJ 2016;354:i2785
  1. Stavros N Stavropoulos, director of endoscopy and adjunct professor of medicine1 2,
  2. David Friedel, associate director of endoscopy and associate professor of clinical medicine1 3,
  3. Rani Modayil, assistant professor of clinical medicine and attending gastroenterologist1 3,
  4. Henry P Parkman, professor of medicine and director of motility laboratory2 4
  1. 1Division of Gastroenterology and Hepatology, Winthrop University Hospital, Mineola, NY 11501, USA
  2. 2Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
  3. 3Stony Brook University, Stony Brook, NY, USA
  4. 4Temple University Hospital, Philadelphia, PA, USA
  1. Correspondence to: S N Stavropoulos sstavropoulos{at}


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. Potential treatments include drugs, endoscopic botulinum toxin injection, balloon dilation, traditional surgery (usually laparoscopic Heller myotomy; LHM), and a novel, less invasive, natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy termed peroral endoscopic myotomy (POEM). The first human POEM was performed in 2008, with the first publication appearing in 2010 and evidence now rapidly accumulating showing POEM to be comparable to traditional surgery in terms of clinical success and radiologic and manometric post-therapy outcomes. 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.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: This article was submitted before we asked authors to involve patients and report any contributions.

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