Achalasia

Achalasia is failure of the muscle (sphincter) in the lower food pipe (oesophagus) to relax.

What is achalasia?

Achalasia is a progressive degenerative disorder of the muscle activity of the oesophagus. Its cause is unknown. Its severity varies from case to case.

The lower oesophageal sphincter acts like a one way valve that is normally closed at rest to stop food and acid in the stomach moving up into the oesophagus (reflux). Normally when we swallow , the lower oesophageal sphincter relaxes to let the food pass into the stomach. In achalasia this relaxation is usually absent.

Failure of the muscle to relax results in an inability to swallow which causes a buildup of food in the oesophagus. A secondary effect is that the muscle contractions in the whole of the oesophagus stop working and the oesophagus becomes enlarged and floppy (mega-oesophagus).

What are the symptoms of achalasia?

  • Difficulty swallowing food and drink
  • Pain when swallowing
  • Regurgitation of undigested food
  • Coughing, especially when lying down
  • Loss of weight
  • Pneumonia if food is inhaled into the lungs

How does your doctor diagnose achalasia?

  • Your doctor may have a suspicion that you have achalasia after taking your medical history.
  • Early in the disease however the symptoms are easily mistaken for reflux disease
  • Oesophageal cancer can also cause similar symptoms
  • Further tests are therefore always  required and they include the following: ~ Barium swallow which is an x-ray after swallowing a liquid which contains barium which shows up as a white shadow on an x-ray film. ~ Oesophageal manometry which measures the pressure of contractions along the oesophagus using a thin plastic tube passed through the nose. This is the gold standard test for confirming the diagnosis.  In achalasia there are no contraction waves down the oesophagus but usually high pressure without relaxation at the lower oesophageal sphincter. ~ Gastroscopy (panendoscopy) during which a specialist endoscopist passes a thin flexible viewing scope through the mouth to view the oesophagus and sphincter. This is usually done under sedation, it is safe and is not painful or uncomfortable.
How can achalasia be treated?

  • Mechanical stretching The lower oesophageal sphincter can be forcefully stretched with a balloon but failure rates are high and over stretching can lead to a perforation. It is therefore going out of favour.
  • Botox injection Botulinum toxin which causes temporary muscle relaxation for up to 3 months can be injected into the lower oesophageal sphincter. Symptoms always recur eventually.
  • POEM This is per-oral endoscopic myotomy. The muscle in spasm may be divided endoscopically but requires a highly experienced endoscopist, is not widely available, is not suitable for all cases and more importantly does not address the issue of acid reflux afterwards
  • Surgery Key hole or laparoscopic surgery is required in most cases. This is called a Heller’s cardiomyotomy where the muscle that will not relax is divided to allow food to pass. It is usually combined with an anti reflux procedure to prevent acid reflux. It is usually very successful.