At our meeting on 21 July a question was asked about the different types of achalasia.
Achalasia is not a simple or consistent problem; sometimes it is an issue about muscle propulsion; sometimes it is predominantly about the failure of the lower oesophageal sphincter (LOS) to relax; sometimes it is a combination of these factors. High resolution manometry has helped to analyse details of the condition, and whereabouts the problems are occurring through the length of the oesophagus, ie around the LOS, or higher up towards the throat. Gastroenterologist John Pandolfino developed the Chicago classification into types of achalasia that can sometimes guide doctors about what kind of treatment is likely to be best:
•Type 1 is predominantly a failure of the lower end of the oesophagus and the LOS to relax. There is little or no muscle pressure in the main body of the oesophagus. This type is reported as being more likely to be amenable to treatment by dilatation, botox or Heller’s myotomy. It can be like a hosepipe with a knot in it where pressure can build up, and treatment will often involve measures to relieve this obstruction.
•Type 2 involves some pressure in the main body of the oesophagus, sometimes intermittent or compartmentalised. This type is less likely to be successfully treated by dilatation and surgical intervention around the LOS, and more likely to respond to medication.
•Type 3 involves premature / spastic / uncoordinated contractions in the body of the oesophagus, and is sometimes regarded as a condition that can only be helped by medication rather than surgical procedures.
These labels are not always helpful for patients. It is sometimes possible, for instance, to alleviate problems with Type 3 by procedures to unblock the cause of the food obstruction and to contemplate making worthwhile improvements in a patient’s condition, with realistic and limited expectations. The treatment tends to be best when concentrating on relieving the dominant symptom, and the patient history can be really important in deciding on treatment. So making improvements without achieving a perfect result can still be worthwhile.
One of the things to remember is that there is not really a cure for achalasia as such at the moment. The surgical and other procedures aim to reduce the symptoms of swallowing difficulty. In many cases this is a really worthwhile thing to do, but it is important that the diagnostic testing is as thorough as possible so that the doctors have the best possible picture of details of the problems.