Clin Endosc.  2023 Sep;56(5):537-545. 10.5946/ce.2023.001.

Role of endoscopy in patients with achalasia

• Han SY
• Youn YH

• KMID: 2546131
• DOI: http://doi.org/10.5946/ce.2023.001

Abstract

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.

Keyword

Endoscopy; Esophageal achalasia; Esophageal motility disorders; Upper gastrointestinal tract

Figure

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  Fig. 1. Diagnostic features of achalasia on endoscopy. (A) Dilatation of the esophageal lumen. (B) Abnormal retention of food and/or liquid remnants in the esophagus. (C) Whitish change and thickening of the esophageal mucosal surface. (D) Functional stenosis of the esophagogastric junction (EGJ), where the endoscope passes through the stenotic segment but the EGJ fails to be dilated by insufflation. (E) Abnormal contraction waves of the esophagus.

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  Fig. 2. Recently introduced endoscopic features highly indicative of achalasia. (A) Pinstripe pattern. (B) Rosette-like esophageal folds. (C) Champagne glass sign.

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  Fig. 3. Endoscopic pneumatic dilatation. (A) The balloon is placed across the lower esophageal sphincter (LES) under endoscopic guidance. (B) The balloon is inflated using fluoroscopy until the obliteration of the waist is seen. (C) The waist of the balloon is completely obliterated. (D) The balloon is deflated completely and removed. The muscle fibers of the LES are disrupted by the streatching of the balloon.

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  Fig. 4. Four-step procedure for peroral endoscopic myotomy. (A) A mucosal incision approximately 13 cm proximal to the esophagogastric junction. (B) Entry to the submucosal space. (C) Submucosal tunneling. (D) Endoscopic myotomy. (E) Closure of the mucosal entry using hemostatic clips.

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  Fig. 5. Spindle veins in the gastric submucosa, one of the major landmarks of the esophagogastric junction during peroral endoscopic myotomy.

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  Fig. 6. Endoscopic images of a patient with achalasia before (A) and after (B) peroral endoscopic myotomy (POEM). The patient shows improvement in pinstripe pattern after POEM but has developed posttreatment gastroesophageal reflux disease.

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