Achalasia

Overview

Achalasia is a rare disorder of the esophagus, the muscular tube that carries food and liquids from the mouth to the stomach. In achalasia, the muscles of the esophagus do not move food downward normally, and the valve at the lower end of the esophagus does not relax properly to let food enter the stomach. This can cause food and liquids to remain in the esophagus, leading to swallowing difficulties and other symptoms.

Achalasia usually develops gradually and may be mistaken for more common conditions such as acid reflux. It can affect adults of any age, although it is more often diagnosed in middle-aged and older adults. The condition is long-term, but several treatment options can help improve swallowing and quality of life. Early medical assessment is important because symptoms can worsen over time and may lead to weight loss, aspiration, or nutritional problems.

Symptoms

The main symptom of achalasia is difficulty swallowing, also called dysphagia. This may involve solid foods, liquids, or both. Symptoms often start mildly and become more noticeable over months or years.

• Difficulty swallowing food or drinks
• A feeling that food is stuck in the chest or throat
• Regurgitation of undigested food or liquid, especially when lying down
• Chest discomfort or pressure that may occur after eating
• Heartburn-like symptoms or a burning sensation
• Coughing, choking, or breathing discomfort if food or liquid enters the airway
• Unintentional weight loss due to reduced food intake
• Bad breath or an unpleasant taste in the mouth from retained food

Because some symptoms can resemble reflux disease or heart-related chest pain, it is important to have persistent or concerning symptoms evaluated by a healthcare professional.

Causes and Risk Factors

The exact cause of achalasia is not fully understood. It is thought to involve damage to the nerves that control the muscles of the esophagus and the lower esophageal sphincter, which is the valve between the esophagus and stomach. When these nerves do not function normally, the esophagus cannot push food effectively, and the valve may remain too tight.

In most people, achalasia is not caused by diet, lifestyle, or stress. It is usually not inherited in a simple way. Rarely, conditions that affect the nerves or muscles, infections, or other diseases can produce symptoms similar to achalasia. For this reason, careful evaluation is needed to confirm the diagnosis and rule out other causes of swallowing difficulty.

Possible factors associated with achalasia may include:

• Changes in the nerve cells of the esophagus
• Autoimmune processes, where the immune system may affect nerve function
• Rare infections or inflammatory conditions
• Other disorders that can narrow or affect the lower esophagus

Diagnosis

Diagnosis of achalasia usually involves a combination of medical history, physical examination, and specialized tests. A gastroenterologist may ask about swallowing problems, regurgitation, weight changes, chest symptoms, and how long the symptoms have been present.

Common tests may include:

• Upper endoscopy: A thin flexible camera is used to examine the esophagus and stomach. This helps check for narrowing, inflammation, retained food, or other conditions that can cause similar symptoms.
• Barium swallow study: The patient drinks a contrast liquid while X-ray images are taken. This can show how the esophagus moves and whether the lower valve opens properly.
• Esophageal manometry: A thin tube measures pressure and muscle activity in the esophagus. This is an important test for confirming achalasia and identifying its pattern.

Additional tests may be recommended depending on age, symptoms, medical history, and examination findings. The aim is to understand the cause of swallowing difficulty and choose the most appropriate treatment approach.

Treatment Options

Treatment for achalasia focuses on helping the lower esophageal valve open more easily so food and liquids can pass into the stomach. Treatment does not usually restore normal nerve function, but it can reduce symptoms and improve swallowing for many patients. The choice of treatment depends on the patient’s age, general health, test results, symptom severity, and local expertise.

Common treatment options include:

• Pneumatic dilation: A balloon is used during an endoscopic procedure to stretch the tight lower esophageal valve. Some patients may need more than one session over time.
• Surgical myotomy: The muscle of the lower esophageal valve is carefully cut to reduce tightness. This may be performed using minimally invasive techniques.
• Peroral endoscopic myotomy: An endoscopic technique in which the tight muscle is divided from inside the esophagus, without external incisions.
• Injection therapy: In selected patients, an injection may be used to relax the lower valve temporarily, especially when other procedures are not suitable.
• Supportive care: Nutritional guidance, eating adjustments, and follow-up care may help manage symptoms and maintain overall health.

After treatment, some people may develop reflux symptoms because the lower valve has been loosened. Ongoing follow-up is important to monitor swallowing, nutrition, reflux, and the need for any further care.

When to See a Doctor

Medical evaluation is recommended if swallowing difficulty persists, worsens, or affects eating and drinking. It is also important to seek care if symptoms are associated with weight loss, frequent regurgitation, coughing during meals, vomiting, or chest discomfort.

Urgent medical attention should be sought for severe chest pain, difficulty breathing, inability to swallow liquids, signs of dehydration, or choking episodes. While achalasia is a chronic condition, timely diagnosis and appropriate management can help reduce complications and support better daily functioning.