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    Attention COACH STUDY participants:

    The principal investigators of the study request that you use the official version of the modified score here.
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    Diagnosis and Management of Achalasia (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Shawn Shah, MD
    Strength
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis

    PPI Trial
    1. Must suspect achalasia if dysphagia to solids and liquids and if regurgitation unresponsive to PPI trial (prevalence = 10 in 100,000).
    Esophageal Motility Testing
    1. All patients with suspected achalasia without mechanical obstruction on endoscopy or esophagram should undergo esophageal motility testing to confirm diagnosis.
    Esophagram
    1. Achalasia diagnosis is supported by dilated esophagus, narrow esophagogastric junction with “bird beak” appearance, aperistalsis, incomplete lower esophageal sphincter relaxation, poor emptying of barium on esophagram.
    Barium Esophagram
    1. If motility testing equivocal, barium esophagram recommended to assess esophageal emptying and esophagogastric junction.
    Endoscopy
    1. Endoscopy to assess gastroesophageal junction and cardia is recommended in all achalasia patients to rule out pseudoachalasia.

    Treatment

    Pneumatic Dilation
    1. Graded pneumatic dilation (PD) or laparoscopic surgical myotomy with partial fundoplication are recommended as initial achalasia therapy (if fit and willing to have surgery).
    Surgical Myotomy
    1. Surgical myotomy and PD should be performed at high-volume centers of excellence.
    Initial Therapy
    1. Initial therapy should be guided by patient age, gender, preference and local institutional experience.
    Botulinum Toxin Injection
    1. In poor surgical candidates, botulinum toxin injection is recommended.
    Pharmacologic Therapy
    1. In patients unwilling or unfit for PD or surgery who fail botulinum toxin, pharmacologic therapy recommended (e.g. calcium channel blockers, long-acting nitrates).

    Follow-up

    Esophagram
    1. Post-therapy follow-up may include esophagram to assess symptom relief and esophageal emptying.
    Surveillance Endoscopy
    1. Surveillance endoscopy for esophageal cancer not recommended (400 endoscopies to detect 1 cancer).
    What do the icons mean?  
    Research PaperVaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol. 2013;108(8):1238-49.