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. Me thods: Achalasic patients were selected as candidates for medical therapy o n the basis of the presence of a slight esophageal dilation (< 5 cm) on X-r ays and a good manometric response to nifedipine administration. These pati ents were asked to take 10-20 mg of nifedipine sublingually 30-45 min befor e each meal for 2 weeks. Chronic medical therapy was continued only in thos e 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 mano metric examination after the first 6 months. Results: Of the 56 patients se lected in the above-mentioned manner, 17 had an insufficient clinical respo nse or severe side effects during the initial trial and did not continue me dical 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 beca use they underwent dilation or myotomy; 4 for unknown reasons, and 5 appare ntly recovered. Esophageal manometry was carried out in 4 of the latter pat ients and revealed that the achalasic motor pattern had been replaced by a near-normal pattern. Conclusions: We believe that medical treatment of acha lasia should be carried out not only in those patients who cannot undergo i nvasive procedures or do not respond well to them, but also in patients wit h initial achalasia selected using the above-mentioned criteria, because re gression of the disease could take place in some of them.