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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
Anne C Travis, MD, MSc, FACG, AGAF


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 tearing its muscle fibers. 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: Sep 2016. | This topic last updated: Apr 12, 2016.
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  1. Spechler SJ. American gastroenterological association medical position statement on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology 1999; 117:229.
  2. Vaezi MF, Richter JE. Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol 1999; 94:3406.
  3. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108:1238.
  4. Kappelle WF, Bogte A, Siersema PD. Hydraulic dilation with a shape-measuring balloon in idiopathic achalasia: a feasibility study. Endoscopy 2015; 47:1028.
  5. Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 1993; 88:34.
  6. Okike N, Payne WS, Neufeld DM, et al. Esophagomyotomy versus forceful dilation for achalasia of the esophagus: results in 899 patients. Ann Thorac Surg 1979; 28:119.
  7. Khan AA, Shah SW, Alam A, et al. Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time. Am J Gastroenterol 1998; 93:1064.
  8. Pasricha PJ, Huang RL, Rai R, Ferris C. Achalasia and Other Motor Disorders. In: Gastrointestinal Disease: An endoscopic approach, Vol I, Part II, Dimarino AJ Jr, Benjamin SB (Eds), Blackwell Science, Ltd, Malden, MA 1997. p.219.
  9. Nair LA, Reynolds JC, Parkman HP, et al. Complications during pneumatic dilation for achalasia or diffuse esophageal spasm. Analysis of risk factors, early clinical characteristics, and outcome. Dig Dis Sci 1993; 38:1893.
  10. Barkin JS, Guelrud M, Reiner DK, et al. Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990; 36:123.
  11. Ciarolla DA, Traube M. Achalasia. Short-term clinical monitoring after pneumatic dilation. Dig Dis Sci 1993; 38:1905.
  12. Barnett JL, Eisenman R, Nostrant TT, Elta GH. Witzel pneumatic dilation for achalasia: safety and long-term efficacy. Gastrointest Endosc 1990; 36:482.
  13. Ghoshal UC, Kumar S, Saraswat VA, et al. Long-term follow-up after pneumatic dilation for achalasia cardia: factors associated with treatment failure and recurrence. Am J Gastroenterol 2004; 99:2304.
  14. Zerbib F, Thétiot V, Richy F, et al. Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia. Am J Gastroenterol 2006; 101:692.
  15. Mehta R, John A, Sadasivan S, et al. Factors determining successful outcome following pneumatic balloon dilation in achalasia cardia. Indian J Gastroenterol 2005; 24:243.
  16. Bravi I, Nicita MT, Duca P, et al. A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term. Aliment Pharmacol Ther 2010; 31:658.
  17. Torbey CF, Achkar E, Rice TW, et al. Long-term outcome of achalasia treatment: the need for closer follow-up. J Clin Gastroenterol 1999; 28:125.
  18. Eckardt VF, Gockel I, Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 2004; 53:629.
  19. Moonen A, Annese V, Belmans A, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2015.
  20. Eckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: patient characteristics and clinical course. Gastroenterology 1999; 116:1300.
  21. Hulselmans M, Vanuytsel T, Degreef T, et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol 2010; 8:30.
  22. Mikaeli J, Fazel A, Montazeri G, et al. Randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for the treatment of achalasia. Aliment Pharmacol Ther 2001; 15:1389.
  23. Vaezi MF, Richter JE. Current therapies for achalasia: comparison and efficacy. J Clin Gastroenterol 1998; 27:21.
  24. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med 2011; 364:1807.
  25. Moonen A, Annese V, Belmans A, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65:732.
  26. Di Nardo G, Rossi P, Oliva S, et al. Pneumatic balloon dilation in pediatric achalasia: efficacy and factors predicting outcome at a single tertiary pediatric gastroenterology center. Gastrointest Endosc 2012; 76:927.
  27. Katz PO, Gilbert J, Castell DO. Pneumatic dilatation is effective long-term treatment for achalasia. Dig Dis Sci 1998; 43:1973.
  28. Csendes A, Braghetto I, Henríquez A, Cortés C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 1989; 30:299.
  29. Karamanolis G, Sgouros S, Karatzias G, et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Am J Gastroenterol 2005; 100:270.
  30. Elliott TR, Wu PI, Fuentealba S, et al. Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience. Aliment Pharmacol Ther 2013; 37:1210.
  31. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103:1732.
  32. Rajput S, Nandwani SK, Phadke AY, et al. Predictors of response to pneumatic dilatation in achalasia cardia. Indian J Gastroenterol 2000; 19:126.
  33. Shahi HM, Aggarwal R, Misra A, et al. Relationship of manometric findings to symptomatic response after pneumatic dilation in achalasia cardia. Indian J Gastroenterol 1998; 17:19.
  34. Rohof WO, Hirsch DP, Kessing BF, Boeckxstaens GE. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 2012; 143:328.
  35. Fellows IW, Ogilvie AL, Atkinson M. Pneumatic dilatation in achalasia. Gut 1983; 24:1020.
  36. Robertson CS, Fellows IW, Mayberry JF, Atkinson M. Choice of therapy for achalasia in relation to age. Digestion 1988; 40:244.
  37. Farhoomand K, Connor JT, Richter JE, et al. Predictors of outcome of pneumatic dilation in achalasia. Clin Gastroenterol Hepatol 2004; 2:389.
  38. Kim CH, Cameron AJ, Hsu JJ, et al. Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation. Mayo Clin Proc 1993; 68:1067.
  39. Lee JD, Cecil BD, Brown PE, Wright RA. The Cohen test does not predict outcome in achalasia after pneumatic dilation. Gastrointest Endosc 1993; 39:157.
  40. Guardino JM, Vela MF, Connor JT, Richter JE. Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy. J Clin Gastroenterol 2004; 38:855.
  41. Kumbhari V, Behary J, Szczesniak M, et al. Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse. Am J Gastroenterol 2013; 108:1076.
  42. Zhu Q, Liu J, Yang C. Clinical study on combined therapy of botulinum toxin injection and small balloon dilation in patients with esophageal achalasia. Dig Surg 2009; 26:493.
  43. Mikaeli J, Bishehsari F, Montazeri G, et al. Injection of botulinum toxin before pneumatic dilatation in achalasia treatment: a randomized-controlled trial. Aliment Pharmacol Ther 2006; 24:983.
  44. Kroupa R, Hep A, Dolina J, et al. Combined treatment of achalasia - botulinum toxin injection followed by pneumatic dilatation: long-term results. Dis Esophagus 2010; 23:100.
  45. Khudyak V, Lysy J, Mankuta D. Achalasia in pregnancy. Obstet Gynecol Surv 2006; 61:207.
  46. Reynolds JC, Parkman HP. Achalasia. Gastroenterol Clin North Am 1989; 18:223.
  47. Eckardt VF, Kanzler G, Westermeier T. Complications and their impact after pneumatic dilation for achalasia: prospective long-term follow-up study. Gastrointest Endosc 1997; 45:349.
  48. Vanuytsel T, Lerut T, Coosemans W, et al. Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol Hepatol 2012; 10:142.
  49. Lynch KL, Pandolfino JE, Howden CW, Kahrilas PJ. Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817.
  50. Borotto E, Gaudric M, Danel B, et al. Risk factors of oesophageal perforation during pneumatic dilatation for achalasia. Gut 1996; 39:9.
  51. Metman EH, Lagasse JP, d'Alteroche L, et al. Risk factors for immediate complications after progressive pneumatic dilation for achalasia. Am J Gastroenterol 1999; 94:1179.
  52. Swedlund A, Traube M, Siskind BN, McCallum RW. Nonsurgical management of esophageal perforation from pneumatic dilatation in achalasia. Dig Dis Sci 1989; 34:379.
  53. Lo AY, Surick B, Ghazi A. Nonoperative management of esophageal perforation secondary to balloon dilatation. Surg Endosc 1993; 7:529.
  54. Elhanafi S, Othman M, Sunny J, et al. Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting. Am J Case Rep 2013; 14:532.
  55. Sanaka MR, Raja S, Thota PN. Esophageal Perforation After Pneumatic Dilation for Achalasia: Successful Closure With an Over-the-Scope Clip. J Clin Gastroenterol 2016; 50:267.
  56. Bell RC. Laparoscopic closure of esophageal perforation following pneumatic dilatation for achalasia. Report of two cases. Surg Endosc 1997; 11:476.
  57. Nathanson LK, Gotley D, Smithers M, Branicki F. Videothoracoscopic primary repair of early distal oesophageal perforation. Aust N Z J Surg 1993; 63:399.
  58. Goldblum JR, Whyte RI, Orringer MB, Appelman HD. Achalasia. A morphologic study of 42 resected specimens. Am J Surg Pathol 1994; 18:327.
  59. Aggestrup S, Uddman R, Sundler F, et al. Lack of vasoactive intestinal polypeptide nerves in esophageal achalasia. Gastroenterology 1983; 84:924.
  60. Mearin F, Mourelle M, Guarner F, et al. Patients with achalasia lack nitric oxide synthase in the gastro-oesophageal junction. Eur J Clin Invest 1993; 23:724.
  61. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Treatment of achalasia with intrasphincteric injection of botulinum toxin. A pilot trial. Ann Intern Med 1994; 121:590.
  62. Katzka DA, Castell DO. Use of botulinum toxin as a diagnostic/therapeutic trial to help clarify an indication for definitive therapy in patients with achalasia. Am J Gastroenterol 1999; 94:637.
  63. Wehrmann T, Schmitt T, Dietrich CF, et al. Manometrically-guided endoscopic injection of botulinum toxin for esophageal achalasia: a pilot trial. Z Gastroenterol 2000; 38:899.
  64. Hoffman BJ, Knapple WL, Bhutani MS, et al. Treatment of achalasia by injection of botulinum toxin under endoscopic ultrasound guidance. Gastrointest Endosc 1997; 45:77.
  65. Annese V, Bassotti G, Coccia G, et al. Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia. The Gismad Achalasia Study Group. Aliment Pharmacol Ther 1999; 13:1347.
  66. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995; 332:774.
  67. Cuillière C, Ducrotté P, Zerbib F, et al. Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin. Gut 1997; 41:87.
  68. Rollan A, Gonzalez R, Carvajal S, Chianale J. Endoscopic intrasphincteric injection of botulinum toxin for the treatment of achalasia. J Clin Gastroenterol 1995; 20:189.
  69. Fishman VM, Parkman HP, Schiano TD, et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. Am J Gastroenterol 1996; 91:1724.
  70. Muehldorfer SM, Schneider TH, Hochberger J, et al. Esophageal achalasia: intrasphincteric injection of botulinum toxin A versus balloon dilation. Endoscopy 1999; 31:517.
  71. Allescher HD, Storr M, Seige M, et al. Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-Up. Endoscopy 2001; 33:1007.
  72. Bassotti G, D'Onofrio V, Battaglia E, et al. Treatment with botulinum toxin of octo-nonagerians with oesophageal achalasia: a two-year follow-up study. Aliment Pharmacol Ther 2006; 23:1615.
  73. Annese V, Basciani M, Borrelli O, et al. Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia. Muscle Nerve 1998; 21:1540.
  74. Kolbasnik J, Waterfall WE, Fachnie B, et al. Long-term efficacy of Botulinum toxin in classical achalasia: a prospective study. Am J Gastroenterol 1999; 94:3434.
  75. Pasricha PJ, Rai R, Ravich WJ, et al. Botulinum toxin for achalasia: long-term outcome and predictors of response. Gastroenterology 1996; 110:1410.
  76. Annese V, Bassotti G, Coccia G, et al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut 2000; 46:597.
  77. Vaezi MF, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut 1999; 44:231.
  78. Ghoshal UC, Chaudhuri S, Pal BB, et al. Randomized controlled trial of intrasphincteric botulinum toxin A injection versus balloon dilatation in treatment of achalasia cardia. Dis Esophagus 2001; 14:227.
  79. Annese V, Basciani M, Perri F, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia. Gastroenterology 1996; 111:1418.
  80. D'Onofrio V, Miletto P, Leandro G, Iaquinto G. Long-term follow-up of achalasia patients treated with botulinum toxin. Dig Liver Dis 2002; 34:105.
  81. Lake JM, Wong RK. Review article: the management of achalasia - a comparison of different treatment modalities. Aliment Pharmacol Ther 2006; 24:909.
  82. Lange O, Bigalke H, Dengler R, et al. Neutralizing antibodies and secondary therapy failure after treatment with botulinum toxin type A: much ado about nothing? Clin Neuropharmacol 2009; 32:213.
  83. Eaker EY, Gordon JM, Vogel SB. Untoward effects of esophageal botulinum toxin injection in the treatment of achalasia. Dig Dis Sci 1997; 42:724.
  84. Mac Iver R, Liptay M, Johnson Y. A case of mediastinitis following botulinum toxin type A treatment for achalasia. Nat Clin Pract Gastroenterol Hepatol 2007; 4:579.
  85. Chao CY, Raj A, Saad N, et al. Esophageal perforation, inflammatory mediastinitis and pseudoaneurysm of the thoracic aorta as potential complications of botulinum toxin injection for achalasia. Dig Endosc 2015; 27:618.
  86. Fitzgerald JF, Troncone R, Sukerek H, Tolia V. Clinical quiz. Sinus tract between esophagus and fundus. J Pediatr Gastroenterol Nutr 2002; 35:38, 98.
  87. Weusten BL, Samsom M, Smout AJ. Pneumothorax complicating botulinum toxin injection in the body of a dilated oesophagus in achalasia. Eur J Gastroenterol Hepatol 2003; 15:561.
  88. Schiano TD, Fisher RS, Parkman HP, et al. Use of high-resolution endoscopic ultrasonography to assess esophageal wall damage after pneumatic dilation and botulinum toxin injection to treat achalasia. Gastrointest Endosc 1996; 44:151.
  89. Wang L, Li YM, Li L. Meta-analysis of randomized and controlled treatment trials for achalasia. Dig Dis Sci 2009; 54:2303.
  90. Prakash C, Freedland KE, Chan MF, Clouse RE. Botulinum toxin injections for achalasia symptoms can approximate the short term efficacy of a single pneumatic dilation: a survival analysis approach. Am J Gastroenterol 1999; 94:328.
  91. Bansal R, Nostrant TT, Scheiman JM, et al. Intrasphincteric botulinum toxin versus pneumatic balloon dilation for treatment of primary achalasia. J Clin Gastroenterol 2003; 36:209.
  92. Vela MF, Richter JE, Khandwala F, et al. The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol 2006; 4:580.
  93. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Cochrane Database Syst Rev 2014; :CD005046.
  94. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78:468.
  95. Spechler SJ. Pneumatic dilation and laparoscopic Heller's myotomy equally effective for achalasia. N Engl J Med 2011; 364:1868.
  96. Pandolfino JE, Kwiatek MA, Nealis T, et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135:1526.
  97. Richardson WS, Willis GW, Smith JW. Evaluation of scar formation after botulinum toxin injection or forced balloon dilation to the lower esophageal sphincter. Surg Endosc 2003; 17:696.
  98. Raftopoulos Y, Landreneau RJ, Hayetian F, et al. Factors affecting quality of life after minimally invasive Heller myotomy for achalasia. J Gastrointest Surg 2004; 8:233.
  99. Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg 2006; 243:579.
  100. Bonavina L, Incarbone R, Antoniazzi L, et al. Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia. Ital J Gastroenterol Hepatol 1999; 31:827.
  101. Finley CJ, Kondra J, Clifton J, et al. Factors associated with postoperative symptoms after laparoscopic Heller myotomy. Ann Thorac Surg 2010; 89:392.
  102. Horgan S, Hudda K, Eubanks T, et al. Does botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc 1999; 13:576.
  103. Rakita S, Bloomston M, Villadolid D, et al. Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome. J Gastrointest Surg 2005; 9:159.
  104. Deb S, Deschamps C, Allen MS, et al. Laparoscopic esophageal myotomy for achalasia: factors affecting functional results. Ann Thorac Surg 2005; 80:1191.
  105. Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg 2001; 136:870.
  106. Jones EL, Meara MP, Pittman MR, et al. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2015.