Achalasia Treatment and Management

Classification and Treatment Response

The British Society of Gastroenterology notes that achalasia is classified into three distinct subtypes (Types I, II, and III) based on high-resolution manometry findings, with Type II having the best treatment response, Type I intermediate, and Type III requiring specialized management with extended myotomy 1, 2
Type II achalasia responds best to all treatment modalities, including botulinum toxin, pneumatic dilation, laparoscopic Heller myotomy (LHM), and per-oral endoscopic myotomy (POEM), with treatment options based on shared decision-making, local expertise, and patient preferences 1, 2, 3, 4
The American College of Gastroenterology recommends that treatment decisions for Type I achalasia should be based on local expertise, therapeutic availability, and patient choice rather than subtype alone, with same treatment options as Type II: pneumatic dilation, LHM, or POEM 1, 2, 3, 4
Type III achalasia consistently demonstrates the poorest response to standard LES-directed therapies across all treatment modalities, with POEM being the preferred treatment when expertise is available, allowing unlimited proximal extension of the myotomy to address spastic esophageal body contractions 1, 2, 3, 4, 5, 6, 7

For Types I and II, pneumatic dilation, LHM, or POEM are all effective first-line options, with decision incorporating patient characteristics, patient preferences, and local expertise 4, 5, 7, 8
For Type III, POEM is the preferred treatment when expertise is available, with myotomy length tailored to the proximal extent of spastic contractions, guided by HRM findings, endoscopic ultrasound, or intraoperative functional luminal imaging probe 5, 6, 4, 7

Patients with severe esophageal dilation and sigmoid deformation can be treated with POEM, though with a higher risk of adverse events, and limited data comparing POEM to LHM as initial therapy in end-stage disease 5, 6, 8
All patients undergoing POEM should be counseled about the high risk of reflux esophagitis, requiring potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy 5, 6, 7
The most critical error is treating Type III achalasia with standard LES-only directed therapy, which consistently yields poor outcomes because it fails to address the spastic esophageal body component 1, 5, 2, 4