Achalasia is an uncommon motility disorder of the upper gastrointestinal tract (click for more information on the digestive system) in which the muscles of esophagus do not relax properly, preventing the passage of food. It typically occurs at the lower esophageal sphincter (LES), a ring of muscle that encircles the esophagus at the entrance to the stomach. When the sphincter closes, food cannot enter the stomach. Reflux of the stomach contents occurs when the sphincter does not close properly, which can result in a feeling of heartburn. The inability to empty the esophagus is due to a lack of peristalsis and/or failure of the coordinated relaxation of the LES during swallowing. It can eventually lead to food avoidance and result in malnutrition and weight loss.
Achalasia symptoms usually worsen over time, leading to the person not tolerating most solids and, eventually, many liquids. These include:
- Dysphagia (inability to swallow), often described as food “getting stuck”
- Regurgitation of food
- Night time cough or recurrent pneumonia
- Vomiting (occasionally)
Many medical experts believe that the degeneration of the nerve cells that signal the brain to relax the esophageal sphincter causes achalasia. Although the underlying cause of this degeneration is unknown, some have proposed an autoimmune disease or infectious source.
Tests that can provide useful information to help a physician form an achalasia diagnose are:
- Esophageal manometry – a tube measures the pressure of the esophageal sphincter (diagnostic test of choice for achalasia)
- X-ray of the esophagus following ingestion of barium contrast liquid
The aim of treatment is to reduce the lower esophageal sphincter pressure to allow food to pass through more easily, using medication, balloon dilatation, or surgery. Occasionally, medications such as calcium channel blockers or nitrate-based compounds will help relieve symptoms of achalasia, but these treatments are generally ineffective in most patients.
Recent studies on endoscopic injection of botulinum toxin into the esophageal wall showed temporary improvement of dysphagia in almost two-thirds of the patients.
Balloon dilatation involves the insertion of an inflatable balloon down the esophagus to the sphincter, where it is inflated to force the sphincter open. This is effective in about 70% of patients but multiple sessions are often required, increasing the risk of esophageal perforation. This method is also usually temporary, and about half the patients develop gastroesophageal reflux (GERD).
The surgery to relieve achalasia is called an esophageal myotomy after which about 90% of patients experience long-term relief. This involves dividing the muscularis of the upper stomach and the lower esophagus.
Nutrition plays an important role prior to, and in conjunction with, these procedures. Consultation with a registered dietitian could prove beneficial as the majority of achalasia patients have lost weight due to food avoidance and are malnourished. A dietitian will most likely recommend foods or liquids that are calorie dense and easily swallowed. If the person is unable to manage swallowing even liquids, they may temporarily need enteral nutrition (tube feeding) through a gastrostomy or PEG (percutaneous endoscopic gastrostomy). There are also foods that can decrease LES pressure (high fat intake, chocolate, peppermint, and caffeine) and patients are encouraged to avoid reclining or bending over after eating.
Achalasia is an uncommon disorder of the esophagus that your physician may treat with a combination of medications, balloon dilatation, surgery, and nutrition. If you are experiencing the symptoms of achalasia, consult your physician.