ACG issues guidelines for the diagnosis and treatment of cardia achalasia Cardia achalasia is a rare but classic primary esophageal dysmotility disorder characterized by incomplete lower esophageal sphincter (LES) diastole and loss of esophageal peristalsis, typically characterized by difficulty swallowing solid and liquid foods, food reflux, and often misdiagnosed as gastroesophageal reflux disease (GERD). The American Journal of Gastroenterology (Am J Gastroenterol) published online on July 23rd the Clinical Guidelines for the Diagnosis and Management of Cardia Flaccida, introducing the progress of cardia flaccida treatment and follow-up management. Diagnostic Recommendations 1. In patients with suspected cardia achalasia, esophageal kinetic testing should be performed before confirming the diagnosis if there are no positive findings on endoscopy or esophageal x-ray. (Strongly recommended, supported by low-quality evidence.) 2. The diagnosis of cardia is supported by the following findings on esophageal X-ray: dilatation of the esophagus; narrowing of the esophagogastric junction (EGJ) with a “beak sign”; loss of esophageal peristalsis; and poor barium esophageal emptying. (Strongly recommended, supported by moderate quality evidence.) 3. For patients with suspicious esophageal kinetic test results, barium swallow X-ray is recommended to assess esophageal emptying function and EGJ morphology. (Strongly recommended, supported by low-quality evidence.) 4. In all patients with cardia, esophageal endoscopy should be performed to visualize the EGJ and gastric cardia morphology to exclude pseudo-cardia. (Strongly recommended, supported by moderate quality evidence) Comments: Patients with cardia achalasia need to undergo barium esophageal meal, endoscopy and esophageal manometry to clarify the diagnosis, and these three tests can provide appropriate diagnostic information from different perspectives. For example, barium meal can show the morphology of the esophagus and its function of emptying barium; endoscopy can clearly show the esophageal lumen, mucosa, cardia and cardia gastric side, and fundus of the stomach with or without lesions that cause cardia-like achalasia; for patients who cannot be diagnosed clearly by barium meal or endoscopy, esophageal manometry can show the characteristic changes of the disease, and high-resolution manometry (HRM) can clearly show the subtype of cardia achalasia and can determine the diagnosis (Table). It is now believed that the above tests are not only complementary in the diagnosis of cardia achalasia, but also help to comprehensively assess the patient’s condition, stage and type of disease, and are an important basis for further management. Treatment recommendations 1. For patients with indications for surgery and who agree to undergo surgery, esophageal balloon dilation (PD) and laparoscopic myotomy combined with partial fundoplication can be used as primary treatment options. （2. Both PD and surgical myotomy should be performed in a surgical center with appropriate medical conditions. (Strongly recommended, supported by low-quality evidence) 3. The choice of primary treatment should be guided by the patient’s age, gender, wishes and the level of local medical institutions. (Weakly recommended, supported by low-quality evidence) 4. Botulinum toxin is recommended for patients without clear indications for surgical treatment of PD and surgical myotomy. (Strongly recommended, supported by moderate quality evidence) 5. Pharmacological treatment is recommended for patients who are unwilling or unable to undergo PD and surgical procedures and for those who have failed botulinum toxin treatment. (Strongly recommended, supported by low-quality evidence) Point: All treatments are based on improving the relaxation of the LES, reducing its resistance, accelerating esophageal emptying and improving symptoms (Figure). To date, no single approach has been able to cure cardia relaxation. Balloon dilatation and surgical treatment are its two main treatments, both of which achieve a good outcome. Laparoscopic myotomy combined with fundoplication can reduce the incidence of reflux esophagitis after myotomy. Newly developed techniques such as transoral endoscopic myotomy (PEOM) or local placement of retrievable stents aim to further increase the efficacy and reduce the damage, and some studies have shown that the above treatment can be effective, but the long-term efficacy remains to be observed and evaluated. Not all patients can receive a particular treatment. Physicians should choose the appropriate treatment based on the patient’s specific circumstances, such as the stage of disease, condition, wishes and the overall strength of the medical center. The long-term effects of cardia treatment are not easy to maintain, and physicians must pay attention to how to maintain the effects of treatment and patient education after treatment. Once diagnosed with this disorder, patients need to be informed of their eating patterns and learn how to manage their esophagus well to avoid food retention exacerbated by improper food blockage, which can lead to esophageal dilatation, horn formation, or even megaesophagus formation, making treatment more difficult. ”Esophageal kinetic testing is necessary for the diagnosis of cardia achalasia, with barium esophageal meal and esophagogastroduodenoscopy (EGD) as its complementary tests, with EGD being used mainly to rule out pseudo cardia achalasia, invasive cancer and eosinophilic esophagitis. With laparoscopic myotomy for cardia achalasia, with or without the addition of fundoplication, patients often have postoperative esophageal reflux and/or abnormal pH tests, and therefore treatment with proton pump inhibitors (PPIs) is recommended for symptomatic patients. Studies have shown that PD is superior to botulinum toxin for the long-term outcome of patients with cardia achalasia, while both have comparable treatment success rates compared to laparoscopic myotomy, but PD remains the most cost-effective treatment for cardia achalasia in terms of cost-benefit analysis.”