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Achalasia

What is the oesophagus?

The oesophagus (gullet) contains muscles. These muscles contract in a rhythmic way to allow your food to pass down your oesophagus. This is known as peristalsis. At the lower end of your oesophagus there is a ring of muscle called a sphincter. This sphincter relaxes to allow food to pass from the oesophagus into your stomach. But, the sphincter contracts when no food is passing down to stop food passing back up (refluxing) into the oesophagus.

What is achalasia?

In the oesophagus there are both muscles and nerves. Achalasia affects both the muscles and the nerves of the oesophagus, especially initially the nerves that cause the sphincter between the oesophagus and stomach to relax. The muscles do not contract properly so peristalsis does not occur correctly. In addition, the sphincter does not relax properly so food cannot pass through into your stomach easily. This makes it difficult for you to swallow food properly.

The main part of your oesophagus then becomes dilated (enlarged and widened) with time.

How common is achalasia and who does it affect?

Achalasia is a very uncommon condition. It only affects around 6,500 people in the UK. It mainly affects adults aged between 20-40 years. In most cases, no underlying cause can be found and the reason why the nerves and muscles in the oesophagus do not work so well is not clear. However, it is more common in people with Chagas’ disease (an infectious disease more common in South America), Parkinson’s disease and stomach cancer. However, the majority of people with these conditions do not have achalasia.

What are the symptoms of achalasia?

The most common symptom is difficulty in swallowing (dysphagia) both foods and liquids. You may also notice that some of your food feels as if it is sticking in your chest after you have eaten. It can also be common to lose weight, as you can not swallow all your food. You may also have some chest pains or a heavy sensation on your chest. Some people also develop a cough, which is sometimes worse at night. Heartburn is also fairly common.

As your oesophagus dilates you may find that some of your food is regurgitated. If this happens during the night you may experience some choking or coughing.

What are the tests for achalasia?

Most people will have had achalasia for a length of time, even for years, before the diagnosis is made. Various tests may be advised if your doctor thinks you may have achalasia. These usually include one or more of the following:

Barium swallow

This is a specialised X-ray test. In this test, X-rays of your oesophagus are taken after you swallow a liquid called barium, which shows up as white on the X-ray. This test will show if your oesophagus is dilated. It will also show if the barium stays in your oesophagus for longer than normal.

Manometry

In this test, the pressure that is generated within your oesophagus when you swallow is monitored. During this test, a thin tube is placed through your nose, down the back of your throat and into your oesophagus. This test can often detect earlier changes than a barium swallow can.

Gastroscopy – sometimes called endoscopy

A gastroscope (endoscope) is a thin, flexible, telescope. It is passed through the mouth, into the oesophagus and down towards the stomach and duodenum. The endoscope contains fibre-optic channels which allow light to shine down so the doctor or nurse can see inside your oesophagus, stomach and duodenum. See separate leaflet called ‘Gastroscopy’ for further details..

What are the treatment options for achalasia?

There are different treatments available. These include:

Medication

Various medicines can help to relax the sphincter at the lower end of the oesophagus. These work best when achalasia is first diagnosed. However, they usually only work in the short-term.

Dilatation

This is a procedure in which the sphincter is dilated. This is done by using a balloon which is inflated to stretch the sphincter. This is done with the use of an endoscope, to ensure the balloon is in the correct position.

Surgery

In some cases, the muscle fibres in the sphincter are divided (cut) during an operation. This is usually done by keyhole surgery. This is usually very successful at easing the symptom of difficulty swallowing. However, it may cause complications such as gastro oesophageal reflux disease. This is when the acid from your stomach comes up into your oesophagus. This can cause heartburn.

Botulism

This is a recent treatment for achalasia. This involves injecting botulism into the sphincter to weaken the muscle. This is usually a safe treatment. However, it only works for a few months so further injections are often necessary. It may be more suitable for people who are unable to have surgery.

What are the possible complications of achalasia?

The main complication of achalasia is weight loss. Another possible complication is that if food is regurgitated, there is a risk that some food can enter the lungs. This can then lead to an infection in the lungs. This type of infection is known as aspiration pneumonia. It is usually treated with antibiotics but it can be more difficult to treat than other types of pneumonia. You are also at increased risk of developing some inflammation of the lining of your oesophagus due to the food and fluid which collect in your oesophagus causing irritation. This is called oesophagitis.

There are also possible complications of some of the treatments. For example, dilatation of the sphincter can sometimes lead to perforation (a puncture) of the oesophagus. If this occurs, it will need an emergency operation to repair it.

There is a slightly increased risk of developing cancer of the oesophagus if it contains a large amount of food which does not pass into the stomach in the normal way. Your doctor will be able to discuss this with you in more detail.

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