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Chapter 4
Figure 3.
Subtypes of achalasia differentiated by manometry and barium swallow
Type I indicates an impaired relaxation of the LOS with lack of peristalsis, but with a normal oesophageal pressure.
Type II is characterised by an increased oesophageal pressure. In type III, additionally spastic contractions of the
distal oesophagus are observed.
Injection with botulinum toxin
Botulinum toxin blocks the release of acetylcholine in neurons. The injection can be
performed endoscopically under mild sedation. It leads to a reduction of symptoms in two-
thirds of the patients with achalasia. Unfortunately, a drawback is that the effect is only
temporary due to the regeneration of neurons and patients typically need to be re-treated
within a year. Alongside, it is a problem that repeated injections with botulinum toxin
complicate Heller myotomy, one of the more definitive treatment options.
1
Pneumatic dilatation
A rigid balloon is placed in the LOS and filled with air (Figure 4). The procedure is performed
under deep sedation. 60-90% of the patients benefit from the dilatation, but approximately
one-third of these patients need to be retreated after a few years. A recent randomised study
showed that repeated pneumatic dilatations are comparable with surgical myotomy.
1,3
The most important complication is perforation of the LOS. The incidence of perforation is
about 1% .
1