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Pneumatic dilation, Heller cardiomyotomy, and POEM provide comparable short- and long-term symptomatic improvement in achalasia types I or II.

For type III (spastic) achalasia, POEM with a long distal myotomy may be preferred to Heller cardiomyotomy where expertise is available.



  • Gradual, progressive dysphagia for solids and liquids.

  • Regurgitation of undigested food.

  • Barium esophagogram with “bird’s beak” distal esophagus.

  • Esophageal manometry confirms diagnosis.

General Considerations

Achalasia is an idiopathic motility disorder characterized by loss of peristalsis in the distal two-thirds (smooth muscle) of the esophagus and impaired relaxation of the LES. There appears to be denervation of the esophagus resulting primarily from loss of nitric oxide–producing inhibitory neurons in the myenteric plexus. The cause of the neuronal degeneration is unknown.

Clinical Findings

A. Symptoms and Signs

There is a steady increase in the incidence of achalasia with age; however, it can be seen in individuals as young as 25 years. Patients complain of the gradual onset of dysphagia for solid foods and, in the majority, of liquids also. Symptoms at presentation may have persisted for months to years. Substernal discomfort or fullness may be noted after eating. Many patients eat more slowly and adopt specific maneuvers such as lifting the neck or throwing the shoulders back to enhance esophageal emptying. Regurgitation of undigested food is common and may occur during meals or up to several hours later. Nocturnal regurgitation can provoke coughing or aspiration. Up to 50% of patients report substernal chest pain that is unrelated to meals or exercise and may last up to hours. Weight loss is common. Physical examination is unhelpful.

B. Imaging

Chest radiographs may show an air-fluid level in the enlarged, fluid-filled esophagus. Barium esophagography discloses characteristic findings, including esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying, and a smooth, symmetric “bird’s beak” tapering of the distal esophagus. Five minutes after ingestion of 8 oz of barium, a column height of more than 2 cm has a sensitivity and specificity of greater than 85% in differentiating achalasia from other causes of dysphagia. Without treatment, the esophagus may become markedly dilated (“sigmoid esophagus”).

C. Special Examinations

After esophagography, endoscopy is always performed to evaluate the distal esophagus and gastroesophageal junction to exclude a distal stricture or a submucosal infiltrating carcinoma. The diagnosis is confirmed by high-resolution esophageal manometry demonstrating absence of normal peristalsis and impaired esophagogastric junction relaxation after swallowing. An integrated post-swallow relaxation pressure greater than 15 mm Hg has a diagnostic sensitivity of 97%. Three achalasia subtypes are recognized based on esophageal contractility and pressure patterns: types I and II (nonspastic) and type III (characterized by distal high-amplitude spastic contractions).

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