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Achalasia

Medically reviewed on Nov 18, 2017

Overview

Achalasia is a rare disorder that makes it difficult for food and liquid to pass into your stomach. Achalasia occurs when nerves in the tube connecting your mouth and stomach (esophagus) become damaged. As a result, the esophagus loses the ability to squeeze food down, and the muscular valve between the esophagus and stomach (lower esophageal sphincter) doesn't fully relax — making it difficult for food to pass into your stomach.

There's no cure for achalasia. But symptoms can usually be managed with minimally invasive therapy or surgery.

Diagnosis

Achalasia can be overlooked or misdiagnosed because it has symptoms similar to other digestive disorders. To test for achalasia, your doctor is likely to recommend:

  • Esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow, the coordination and force exerted by the esophagus muscles, and how well your lower esophageal sphincter relaxes or opens during a swallow.
  • X-rays of your upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine. You may also be asked to swallow a barium pill that can help to show a blockage of the esophagus.
  • Upper endoscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Endoscopy can be used to define a partial blockage of the esophagus if your symptoms or results of a barium study indicate that possibility. Endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications of reflux such as Barrett's esophagus.

Read more about esophageal manometry and upper endoscopy.

Treatment

Achalasia treatment focuses on relaxing or forcing open the lower esophageal sphincter so that food and liquid can move more easily through your digestive tract.

Specific treatment depends on your age and the severity of the condition.

Nonsurgical treatment

Nonsurgical options include:

  • Pneumatic dilation. A balloon is inserted into the esophageal sphincter and inflated to enlarge the opening. This outpatient procedure may need to be repeated if the esophageal sphincter doesn't stay open. Nearly one-third of people treated with balloon dilation need repeat treatment within six years.
  • Botox (botulinum toxin type A). This muscle relaxant can be injected directly into the esophageal sphincter with an endoscope. The injections may need to be repeated, and repeat injections may make it more difficult to perform surgery later if needed. Botox is generally recommended only for people who aren't good candidates for pneumatic dilation or surgery due to age or overall health.
  • Medication. Your doctor might suggest muscle relaxants such as nitroglycerin (Nitrostat) or nifedipine (Procardia) before eating. These medications have limited treatment effect and severe side effects. Medications are generally considered only if you're not a candidate for pneumatic dilation or surgery, and Botox hasn't helped.

Surgery

Surgery may be recommended for younger people because nonsurgical treatment tends to be less effective in this group. Surgical options include:

  • Heller myotomy. The surgeon cuts the muscle at the lower end of the esophageal sphincter to allow food to pass more easily into the stomach. The procedure can be done noninvasively (laparoscopic Heller myotomy). People who have a Heller myotomy may later develop gastroesophageal reflux disease (GERD).
  • Fundoplication. The surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent acid reflux. Fundoplication might be performed at the same time as Heller myotomy, to avoid future problems with acid reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure.
  • Peroral endoscopic myotomy (POEM). The surgeon uses an endoscope inserted through your mouth and down your throat to create an incision in the inside lining of your esophagus. Then, as in a Heller myotomy, the surgeon cuts the muscle at the lower end of the esophageal sphincter. POEM doesn't include an anti-reflux procedure.

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