Medical therapy of achalasia: A benefit reserved for few

Background: The rationale for medical therapy of initial achalasia and the results obtained over the last 20 years in our laboratory are presented. Methods: Achalasic patients were selected as candidates for medical therapy on the basis of the presence of a slight esophageal dilation (< 5 cm) on X-rays and a good manometric response to nifedipine administration. These patients were asked to take 10-20 mg of nifedipine sublingually 30-45 min before each meal for 2 weeks. Chronic medical therapy was continued only in those with an 'excellent' or 'good' clinical response to nifedipine and a lack of severe side effects. X-ray controls were planned every 6 months and manometric examination after the first 6 months. Results: Of the 56 patients selected in the above-mentioned manner, 17 had an insufficient clinical response or severe side effects during the initial trial and did not continue medical therapy. Of the 39 patients who started chronic medical treatment, 13 are still on therapy and 26 stopped after an average of 2.8 years: 17 because they underwent dilation or myotomy; 4 for unknown reasons, and 5 apparently recovered. Esophageal manometry was carried out in 4 of the latter patients and revealed that the achalasic motor pattern had been replaced by a near-normal pattern. Conclusions: We believe that medical treatment of achalasia should be carried out not only in those patients who cannot undergo invasive procedures or do not respond well to them, but also in patients with initial achalasia selected using the above-mentioned criteria, because regression of the disease could take place in some of them.