Richter suggested a treatment algorithm for patients with achalasia. The goal of therapy is to reduce the pressure gradient across lower esophageal sphincter sufficient to facilitate esophageal emptying by gravity. The author is from the Cleveland Clinic in Cleveland, Ohio.


If the person is a low surgical risk AND is willing to have surgery:

(1) Either laparoscopic myotomy or graded pneumatic dilation may be tried first.

(2) If the first procedure fails, then the other procedure may be tried.

(3) If the second procedure fails, then consider esophagectomy with reconstruction.


If the person is a high surgical risk OR is unwilling to have surgery:

(1) Botulinum toxin A (80 – 100 units) may be injected endoscopically into the lower esophageal sphincter.

(2) If this fails after the first attempt, a second dose may be administered.

(3) If the second administration of botulinum toxin fails, then a smooth muscle relaxant (isosorbide dinitrate) or a calcium channel blocker (nifedipine) may be administered before meals or PRN for pain and dysphagia.


Problems with different therapies:

(1) Pneumatic dilatation may cause esophageal perforation.

(2) Myotomy may result in uncontrolled gastro-esophageal reflux.

(3) Drug therapy provides variable relief and effectiveness may decrease over time.

(4) Patients treated with botulinum toxin may have recurrence of problems within a few months.


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