Achalasia – Diagnosis and Treatment
Diagnosis
Doctors often use several tests to identify achalasia because its symptoms—such as difficulty swallowing, chest pain, heartburn, regurgitation, and weight loss—resemble those of other conditions like gastroesophageal reflux disease or esophageal cancer.
Key diagnostic tools include:
| Test Name | What It Checks For | Key Insights |
|---|---|---|
| Esophageal Manometry | Measures esophageal muscle contractions and the function of the lower esophageal sphincter (LES) during swallowing. | Most accurate test for motility disorders, can detect poor LES relaxation and aperistalsis. |
| Barium Swallow (X-ray) | Shows the outline of the esophagus, stomach, and upper intestine after swallowing barium. | Reveals delayed esophageal emptying, dilation, and a narrowed LES (bird beak appearance). |
| Upper Endoscopy | Uses a small camera to inspect the inner esophagus and upper digestive tract. | Helps rule out blockages, pseudoachalasia, or tumors; can take tissue biopsies. |
| FLIP Technology | Assesses esophageal distensibility and function using a special probe. | Confirms diagnosis when manometry or endoscopy is unclear. |
Symptoms of achalasia often include trouble swallowing both solids and liquids, regurgitation of food, and chest pain.
Esophageal manometry provides the gold standard for diagnosis, showing loss of peristalsis and failure of the LES to relax.
Barium studies add detail about the structure and function of the esophagus, while endoscopy checks for secondary causes like cancer or pseudoachalasia.
Doctors may order additional tests like a timed barium swallow or high-resolution manometry to gather more details about the severity and type of esophageal motility disorder.
Treatment
Medicine-Free Approaches
Nonsurgical methods aim to ease symptoms by expanding or relaxing the lower end of the esophagus.
Doctors usually recommend these treatments for people who cannot undergo surgery or who prefer less invasive options.
Balloon Expansion (Pneumatic Dilation)
During this outpatient procedure, a doctor places a balloon at the tight spot of the esophagus and gently inflates it to stretch and widen the lower esophageal sphincter.
Some people need more than one session, as the opening can tighten again. About a third of patients require repeat treatments within five years. Sedation keeps patients comfortable.
Botulinum Toxin Injections
A doctor injects a muscle relaxant (botulinum toxin) into the sphincter muscle using a thin, flexible tube called an endoscope. This relaxes the muscle and lets food pass more easily.
The effect often lasts for a few months, so repeated injections may be necessary. However, multiple uses in the same person can make later surgery more difficult.
Doctors mostly use this option when other therapies are not possible due to age or medical risk.
Medications
Doctors may prescribe medicines like calcium channel blockers or nitroglycerin. Patients take these before meals to relax the muscle at the base of the esophagus.
Their results are usually weaker compared to other approaches, and side effects may limit their use. These drugs serve as a last resort when other nonsurgical treatments are not suitable.
| Nonsurgical Options | Method | Duration | Key Points |
|---|---|---|---|
| Balloon Expansion | Balloon inflated in sphincter | May need repeat | Most common, can require redo |
| Botulinum Toxin | Injection via endoscope | Months | For those unfit for surgery |
| Medication | Pills before meals | Short-term use | Used when other options are not possible |
Surgical Procedures
If medicine-free methods do not work, or if longer-lasting results are needed, doctors might suggest surgery. There are a few main types, each designed to help the esophageal sphincter let food pass more easily.
| Surgery Name | How It’s Done | GERD Risk | Prevention of GERD |
|---|---|---|---|
| Heller Myotomy (laparoscopic) | Cuts lower muscle | Possible | Wrap stomach (fundoplication) |
| Peroral Endoscopic Myotomy (POEM) | Cuts lower muscle from inside | Possible | Medication or fundoplication |
Esophageal Muscle Cutting (Heller Myotomy)
In this surgery, the surgeon cuts the tight muscle at the end of the esophagus. The surgeon often uses small cuts and a special camera, known as a laparoscopic technique.
Sometimes, this procedure causes acid from the stomach to flow back into the esophagus (GERD). To prevent this, the surgeon might wrap part of the stomach around the lower esophagus, a process called fundoplication, to stop stomach acid from moving upward.
Endoscopic Muscle Cutting (POEM)
In peroral endoscopic myotomy (POEM), the doctor passes a flexible tube with a camera through the mouth. The doctor makes a small cut in the inside lining of the esophagus, then slices through the muscle that is causing blockage.
POEM is less invasive, but some people develop heartburn after the procedure. If this happens, some use long-term medications, while others undergo another operation to prevent acid reflux.
