Achalasia is a condition of the esophagus (the tube connecting the mouth to the stomach through which food passes) which makes swallowing food or liquids through the esophagus difficult. Normally, food passes from the mouth the stomach through the esophagus with the assistance of the coordinated movement of the muscles in the esophagus moving in waves to pass food into the stomach, a process called peristalsis. Achalasia involves both the muscles in the esophagus and the lower esophageal sphincter (LES) not working properly. The LES is the band of muscle in between the esophagus and stomach which helps keep food in the stomach when it gets there. In achalasia, the LES can be either too tight or not being able to relax adequately. These changes are caused either by the nerves that control the esophagus or previous problems with the esophagus like esophageal cancer. Difficulty swallowing can also be a symptom of more serious conditions, like cancer of the esophagus, so this symptom should always be evaluated by a doctor.
Difficulty swallowing, chest pain, regurgitation of food
The diagnosis is of achalasia is usually suspected after a history and physical exam, but is confirmed through some testing done by gastroenterologists. One of these tests is a Barium X-ray, which involves swallowing a barium solution followed by taking an X-ray of the esophagus. The barium solution has a characteristic appearance on X-ray and drains into the stomach more slowly than normal in people with achalasia. Diagnosis can also be made with endoscopy, where a thin scope is placed down the esophagus while the patient is under anesthesia. The scope is most helpful to make sure there are no masses in the esophagus which are indicative of cancer. A final option for diagnosis is esophageal manometry. While a patient is under anesthesia, a thin probe is placed in to the esophagus to measure the pressure in the esophagus while the patient is swallowing. People with achalasia have both decreased pressure created by the muscles down the esophagus and increased pressure at the bottom of the esophagus where the LES does not relax appropriately.
A wide range of options are available for treatment of achalasia. Medications can be taken orally to relax the LES prior to each meal. Oral medication is generally only used for people who cannot have surgery done or in whom botulinum toxin injections do not work. Botulinum toxin (Botox) can be injected in to the lower esophageal sphincter (LES) while a patient is under anesthesia. Botulinum toxin is made by bacteria and is a toxin which can cause a type of paralysis called botulism if taken by mouth. However, no person has ever gotten botulism from injection in the esophagus. Though these injections can have good effects on symptoms, the injection needs to be repeated every few months as the effects wear off. In general, surgery is a better long-term option for those who can have it done. Pneumatic Dilation or Balloon Dilation is another treatment which involves passing a small balloon in the LES then filling that balloon with air to stretch out the LES. Most of the time, this procedure only needs to be done one time. There is a small risk of tearing the esophagus when doing this procedure. If this happens, emergent surgery to repair that tear is necessary. Gastroenterologists can also do surgery called a myotomy which involves looking into the esophagus with a scope, then making a very small slit through the muscle of the LES which is too tight. This procedure can require staying the hospital for 1-2 days. This procedure generally needs to be done only once but can require repeat if a stricture (a tightened area of scar) develops. Sometimes the surgery to cut the LES is done in an open surgery. This surgery usually requires a longer hospitalization and recuperation time.
