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.
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Alan_M
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I hadn’t realized there were different “types” of achalasia. I had a Heller fundoplication in 2014. I have recently been diagnosed with a ‘failing esophagus ‘. How does this fall into this scale? I am in the U.S. and don’t plan on another surgery—at least at this time.
Really sorry that we did not pick this post up before. I think that there are various terms for 'end stage' achalasia, when the oesophagus gets baggy and distended and allows food to pool at the bottom, and below the lower oesophageal sphincter where food enters the stomach, and does not clear the food at all. So I guess that 'failing oesophagus' denotes that there is little tone left in the oesophageal wall. Most likely these cases are Type 1 and where the muscles have stopped working completely, but this may not necessarily be so.
I am not sure whether at this point there are any surgical options other than an oesophagectomy where the oesophagus is removed completely. People do undergo this surgery but it is major and with lots of consequences for the digestive system, but it gets to the point where it is a better option than living with the achalasia. One of the dangers of food remaining in the oesophagus is that it can find its way up into your lungs and this can cause repeated pneumonia which is not good for health. Whatever happens you do need to see an experienced specialist surgeon in a specialist centre.
We are based in the UK but do hear of some people having good treatment in good specialist centres in the US but you would have to bear with us as we do not always understand a different healthcare system!
I do understand the navigation of the different health care systems. I sure has been a slow process here getting stuff done! I think that is simply because I’m pretty stable right now. I’m not loosing weight. I have had trouble—fairly mild so far of aspiration. I think the term ‘failing esophagus ‘ denoted no peristalsis, or what was assumed as none. Yes, I’ve had the manometric test (I think that’s close to the name!) and yes, there is no peristalsis. I’m scheduled for a GI test the beginning of August. The thought by the specialist is that I have esophagitis. Which I had on my last upper GI with thrush. I gather Sjogren’s often has this, and is probably the reason I have achalasia because of the neurological component to this disease. I’ll talk to my rheumatologist about this when I see her, also the beginning of August.
I don’t think there is much else done for the esophagus but a resection removing the lower esophagus and forming the stomach to receive the food from the upper esophagus. I’m also not at that point of having to make that decision!
Thrush is miserable. There are some hints about dealing with it in 'A Patient's Guide to Achalasia' that you can download here: achalasia-action.org/inform... but the doctor may well give you medication as well.
You are quite right about the name of the test - manometry.
If your condition is not getting worse, and you can get food into your stomach with gravity, then it may not be necessary to have an oesophagectomy yet, but it will all depend on the details of your condition.
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