Symptom pattern
Dysphagia to solids/liquids, regurgitation, weight loss and warning features are considered together.
POEMDOKTORU.COM · ACHALASIA & THIRD-SPACE ENDOSCOPY
From difficulty swallowing to the right POEM decision.
POEM is not the answer to every swallowing problem. Diagnosis, achalasia subtype, objective testing, alternatives and post-POEM reflux all matter before treatment is chosen.
ACGASGEESGESAGESEvidence-led content architecture
FOCUS PROCEDUREPOEMPeroral Endoscopic Myotomy
01
WHERE ARE YOU STARTING?
Four entry points built around the patient’s real question.
02I have an achalasia diagnosis
Understand subtypes, testing, treatment options and follow-up.
→ 03POEM has been recommendedReview indications, steps, alternatives, risks and reflux considerations together.
→ 04I want a second opinionLearn how existing endoscopy, manometry and imaging records can be reviewed.
→02
A POEM DECISION DOES NOT COME FROM ONE TEST
Symptoms → diagnosis → subtype → option comparison → shared decision
Endoscopic assessment
Stricture, malignancy and structural mimics are evaluated in context.
High-resolution manometry
A core objective test for diagnosing achalasia and defining subtype.
Complementary testing
Timed barium oesophagram and/or EndoFLIP may add information when clinically appropriate.
Compare treatments
POEM, laparoscopic Heller myotomy and pneumatic dilation are compared for the individual patient.
Follow-up and reflux
Clinical response and the possibility of post-procedure gastro-oesophageal reflux both require a plan.
03
WHAT IS POEM?
A tunnel-based myotomy performed through the endoscope, without an external surgical incision.
POEMPeroral Endoscopic Myotomy
The goal is to reduce the functional outflow obstruction in appropriately selected patients. Technical planning is individualized to disease pattern and patient findings.
- 01Mucosal entryAn endoscopic entry point is created.
- 02Submucosal tunnelA controlled tunnel provides access to the muscle layer.
- 03MyotomyThe planned muscle fibres are divided in a controlled manner.
- 04ClosureThe mucosal entry is closed endoscopically.
Important distinction
Difficulty swallowing alone is not an indication for POEM. Achalasia-like symptoms may also occur with eosinophilic oesophagitis, stricture, reflux, diverticula or malignancy.
04
COMPARE TREATMENT OPTIONS
Not “the best procedure” — the right option for the right patient.
| Option | Approach | Key decision point |
|---|---|---|
| POEM | Endoscopic tunnel + myotomy | The ability to extend myotomy can be important, particularly in spastic/type III achalasia; reflux risk should be discussed separately. |
| Heller myotomy | Laparoscopic surgical myotomy | A surgical option commonly paired with fundoplication; patient factors and local expertise matter. |
| Pneumatic dilation | Controlled balloon dilation | Can be effective in selected patients; retreatment needs and perforation risk form part of the decision. |
Current guidelines frame treatment choice around achalasia subtype, patient factors, prior treatment, reflux considerations and local expertise.
05
WHAT IF IT IS NOT POEM?
Not every achalasia-like presentation is achalasia.
DIFFERENTIALEosinophilic Oesophagitis
A chronic immune-mediated inflammation of the oesophagus and an important cause of dysphagia and food impaction.
→DIFFERENTIALOesophageal StrictureNarrowing of the oesophagus from reflux, inflammation, treatment or other causes, often causing solid-food dysphagia.
→DIFFERENTIALOesophageal CancerCancer arising from the oesophageal lining, requiring stage-specific multidisciplinary care.
→DIFFERENTIALZenker’s DiverticulumA pouch at the pharyngo-oesophageal junction that may cause dysphagia, regurgitation and aspiration.
→DIFFERENTIALGastro-oesophageal Reflux Disease (GERD)A chronic condition in which stomach contents reflux into the oesophagus, causing heartburn, regurgitation or throat sy…
→DIFFERENTIALHiatal HerniaMovement of part of the stomach through the diaphragmatic hiatus; it may contribute to reflux but is not always symptom…
→SG06
REFERENCES · EVIDENCE-FIRST
POEM pages speak with visible sources.
SAGES · 20252024 Update to SAGES guidelines for the use of peroral endoscopic myotomy (POEM) in the treatment of achalasiaOpen source ↗American College of Gastroenterology (ACG) · 2020ACG Clinical Guidelines: Diagnosis and Management of AchalasiaOpen source ↗ASGE · 2020ASGE guideline on the management of achalasiaOpen source ↗American Gastroenterological Association (AGA) · 2017Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in AchalasiaOpen source ↗Turkish Journal of Gastroenterology · 2020Clinical usefulness of esophagogastric junction distensibility measurement in patients with achalasia before and after peroral endoscopic myotomyOpen source ↗Esophagus · 2021Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international studyOpen source ↗
INTERNATIONAL PATIENTS
Clarify records, diagnosis and plan before you travel.
For international patients, the aim is not to “sell a procedure” but to understand existing records, manometry and endoscopy findings and establish the appropriate review pathway before travel.
01Share records02Clinical review03Clarify the plan04Travel / procedure05Follow-up at home
International Patient Guide →START WITH THE RIGHT QUESTION
Do you already have manometry, endoscopy or a POEM recommendation?
Review the patient guide and, when appropriate, contact the team for an appointment or second opinion.
