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Pneumatic dilation and botulinum toxin injection for achalasia

Linda Nguyen, MD
Pankaj J Pasricha, MD
Section Editor
Nicholas J Talley, MD, PhD
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Achalasia is an esophageal smooth muscle motility disorder in which the lower esophageal sphincter (LES) fails to relax. It is thought to result from a selective loss of inhibitory nitrinergic neurons (which contain nitric oxide synthase) in the myenteric plexus, resulting in relatively unopposed excitation by the cholinergic system. Clinical symptoms include dysphagia, chest pain, regurgitation, heartburn, and weight loss. The diagnosis is confirmed by esophageal manometry.

There is no cure for achalasia. Treatment is focused on palliating symptoms by decreasing LES pressure to facilitate emptying of esophageal contents. This can be accomplished by mechanical disruption of the muscle fibers of the LES (eg, with pneumatic dilation or surgical myotomy) or by biochemical reduction in LES pressure (eg, with injection of botulinum toxin). For patients at low surgical risk, treatment aimed at mechanical disruption of the LES is generally recommended [1,2].

This topic will review the advantages and disadvantages of pneumatic dilatation and botulinum toxin injection for the management of achalasia. The pathophysiology, etiology, clinical manifestations, diagnosis, and surgical therapy of achalasia are discussed separately. (See "Pathophysiology and etiology of achalasia" and "Achalasia: Pathogenesis, clinical manifestations, and diagnosis" and "Overview of the treatment of achalasia" and "Surgical myotomy for achalasia".)

The recommendations that follow are consistent with a 2013 guideline [3] from the American College of Gastroenterology.


Pneumatic dilation (PD) weakens the lower esophageal sphincter (LES) by circumferential stretching and in some cases, tearing of its muscle fibers [4]. A number of different balloon dilators have been used (eg, Mosher bag, Sippy dilators, Brown-McHardy dilator, Rider-Moeller dilator), but most are no longer being manufactured. At present, the most popular pneumatic dilator in the United States is the Rigiflex balloon.

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Literature review current through: Nov 2017. | This topic last updated: Jan 03, 2017.
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