Targeting the acid pocket: evaluation of a candidate cornerstone of GERD treatment

Achalasia is an uncommon chronic motility disorder of the esophagus with an annual incidence of 1 per 100.000 persons, characterized by absence of peristalsis and defective relaxation of the lower esophageal sphincter (LES). Resulting in impaired bolus propulsion and stasis of food, with dysphagia and regurgitation as main symptoms. The cause of achalasia remains unknown, therefore treatment is confined to dilation or myotomy of the LES. Long-term management of achalasia is challenging. First, a majority of patients requires retreatment during the course of the disease. However, there is no consensus on patient selection. The latter is important to avoid stasis of food, even asymptomatic, in view of the risk for dysplasia and development of mega-esophagus, associated with higher morbidity and refractory symptoms. Second, it still remains unclear if patients with longstanding achalasia should be screened for dysplasia. Due to misinterpretation of symptoms caused by esophageal carcinoma as exacerbation of achalasia, the diagnosis is mostly made in an advanced stage of disease, illustrating the need for early detection of dysplastic lesions. Detection of dysplasia in achalasia requires high resolution advanced endoscopy combined with molecular detection of genetic abnormalities. We aim to improve long-term management of patients with achalasia by validating functional markers selecting patients for retreatment, and by evaluating new approaches to detect esophageal dysplasia.