What is Achalasia?

Achalasia Explained: Types, Symptoms & Relief Options 

Achalasia is a rare condition that affects the oesophagus, the muscular tube that carries food from the throat to the stomach. In individuals with this condition, the lower esophageal sphincter (LES) does not open properly during swallowing. The LES is a ring of muscle that typically stays closed to keep the oesophagus and stomach separate but briefly opens during swallowing to let food move into the stomach.

Its symptoms often begin slowly and tend to worsen gradually as time passes. As the condition advances, swallowing both solids and liquids can become increasingly difficult, often requiring medical intervention for relief.

Keep reading to learn about achalasia, including its symptoms, types, causes, treatment options, and more.

What are the symptoms of achalasia?

The symptoms of achalasia include:

• Inability to swallow (dysphagia)
• Chest pain that comes and goes
• Heartburn
• Regurgitating food or saliva
• Pneumonia (from aspiration of food into the lungs)
• Coughing at night
• Weight loss
• Vomiting
• Belching

What are the types of achalasia?

Achalasia is a heterogeneous disorder that is divided into three main subtypes, each identified by specific manometric findings, which measure the pressure and movements of the oesophagus during swallowing. Check them out below:

1. Type I (Classic Achalasia) : In this form, the oesophagus shows little to no movement of food towards the stomach. There is minimal muscular activity, meaning the oesophagus is largely inactive when attempting to transport swallowed material.
2. Type II : This variant is marked by increased pressure within the oesophagus. The entire length of the oesophagus periodically generates uniform pressure (panesophageal pressurisation) in an effort to move food downward. However, these pressure waves are inconsistent, leading to difficulty in effective swallowing.
3. Type III (Spastic Achalasia) : Often referred to as spastic achalasia, this is the most severe type. It features uncoordinated, premature, or spastic muscle contractions in the lower portion of the oesophagus, close to where it connects with the stomach. These uncoordinated contractions may trigger sharp chest pain that can occur suddenly, sometimes interrupting sleep, and often resembling heart attack symptoms.

What is the cause of achalasia?

The precise cause of achalasia remains unclear. However, experts suggest that multiple factors may contribute to its development, such as:

• A hereditary tendency or a family background of the disorder
• An autoimmune reaction, where the immune system wrongly targets and damages the body’s own healthy tissues. In achalasia, this often leads to the gradual breakdown of nerves within the oesophagus, contributing to the development of symptoms.
• Nerve damage that affects the lower esophageal sphincter (LES) or the oesophagus.

How to Diagnose Achalasia?

Several tests are performed to diagnose achalasia, which are mentioned below:

• Esophagram (Barium Swallow X-ray) : In this imaging test, a patient ingests a contrast liquid that coats the lining of the upper gastrointestinal tract. The contrast allows clear visualisation of the oesophagus, stomach, and upper part of the small intestine on X-ray. A barium tablet may also be used to detect any narrowing or obstruction within the oesophagus.
• Oesophageal Manometry : This is the most definitive test for diagnosing achalasia. It evaluates the muscle activity in the oesophagus during swallowing, including the strength and coordination of muscular contractions and the relaxation of the lower oesophageal sphincter (LES). Manometry is particularly effective in identifying specific types of oesophageal motility disorders.
• Upper Endoscopy : A gastroenterologist performs this procedure using a slender, flexible tube fitted with a light and a camera to inspect the interior of the oesophagus and stomach. This test helps identify any physical blockage or structural abnormalities. It can also be used to obtain tissue samples (biopsies) for evaluating possible complications, such as Barrett’s oesophagus, particularly when symptoms or imaging results suggest that further investigation is needed.

What is the treatment for achalasia?

Although achalasia cannot be entirely cured, several treatment options are available to help manage its symptoms effectively:

• Surgical Options : Surgery remains the most effective approach for long-term symptom relief in individuals with achalasia. The most common surgical technique is Heller myotomy, which involves cutting the muscles at the lower end of the oesophageal sphincter to allow smoother passage of food into the stomach. If the procedure is performed with minimally invasive techniques through small cuts, it is known as laparoscopic Heller myotomy.
• Peroral Endoscopic Myotomy (POEM) : In this procedure, a flexible endoscope is inserted through the mouth and passed down the throat to access the oesophagus. The surgeon makes a cut in the inner layer of the oesophagus to reach and divide the muscle at the lower oesophageal sphincter, following a technique comparable to Heller myotomy.
• Botulinum Toxin (Botox) Injections : In this less invasive option, Botox is injected directly into the stiff muscles of the oesophagus during an endoscopic procedure. This temporarily relaxes the muscles, making it easier to swallow. However, the effects are not permanent and may require repeated treatments.
• Pneumatic Dilation : In this procedure, a balloon is placed within the lower esophageal sphincter and inflated to stretch the muscle, allowing food to move into the stomach with less difficulty. Performed as an outpatient procedure, it may need to be repeated if the sphincter narrows again. Approximately 30% of patients undergoing balloon dilation require additional sessions within 5 years.
• Medications : In some cases, muscle relaxants such as nitroglycerin or nifedipine may be prescribed before meals to help ease swallowing. These medications are usually reserved for patients who are not suitable candidates for surgery, pneumatic dilation, or Botox injections due to potential side effects and limited long-term effectiveness.

By understanding achalasia, you can recognise its symptoms and opt for timely treatment, thereby reducing the chances of complications.

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