What is Achalasia?

Achalasia is an esophageal disease that inhibits normal esophageal emptying. In patients with Achalasia, specific esophageal nerve fibers are damaged. The esophagus loses its capacity to push, and the valve at the lower end of the esophagus (also known as the lower esophageal sphincter) does not relax adequately, leading to difficulties swallowing and a number of accompanying symptoms. Achalasia is in many respects the opposite of GERD, but often patients have similar “heartburn” symptoms so are treated for GERD for many years before the correct diagnosis is made. Achalasia patients have an abnormally tight lower esophageal sphincter, whereas GERD patients have a weaker lower esophageal sphincter. Both illnesses can have a significant influence on a patient’s quality of life and, if left untreated, can result in more serious health problems.

Achalasia, like GERD, can occur at any age, but is more prevalent in middle-aged and older people. It affects men and women equally, and no specific causes have been identified.


Symptoms of Achalasia

Achalasia patients may experience any number of symptoms, however the following are the most common:

  • Dysphagia or food or liquid just sitting in the chest region
  • Chest Pain, especially after eating a few bites
  • Regurgitation of liquids and undigested solid food
  • Heartburn
  • Weight Loss
  • Pneumonia / Aspiration
  • Vomiting

How to Diagnose Achalasia

There are two primary diagnostic tests used to identify Achalasia. These are essential for determining which subtype of achalasia a patient has, which has a significant impact on the treatment regimen.

  • Timed Barium Esophagram: a specialized xray where liquid barium is administered in a specific sequence and xrays taken at specific times after swallowing to assess if there is any delay in passage
  • Esophageal Manometry or Motility Testing: the “gold standard” for diagnosing and further classifying achalasia into subtypes. Specially trained GI nurses insert a small tube containing a pressure gauge system into the esophagus and stomach. The patient swallows an electrolyte solution which quantifies the strength and effectiveness of the esophagus and lower esophageal sphincter.

Treatment of Achalasia

There are multiple therapeutic options available to minimize the symptoms of Achalasia, but Achalasia is a lifelong illness for which there is presently no “cure”. No intervention will be able to restore the motility of the esophagus to its normal state. All interventions are directed at decreasing the barrier caused by the tight lower esophageal sphincter in order to allow easier passage of liquids and solids into the stomach.

achalasia treatment
There are a few drugs on the market that have a side effect of partially relaxing the LES; however, the majority of them are not very successful. Achalasia medications frequently fail to be effective and must be used for the rest of the patient’s life. They are reserved for high risk patients that are not candidates for more effective options.
Botox can be used to treat Achalasia temporarily. Botox is injected into the esophageal muscle at the junction of the stomach and esophagus to relax the LES. Botox generally provides short-term improvement for achalasia sufferers, but it is not a long term solution.
The best nonsurgical treatment for Achalasia is balloon dilation, which should be investigated for those who are not surgical candidates. A balloon is inserted through the mouth and into the valve between the esophagus and stomach during an endoscopy combined with fluoroscopy. The balloon is then inflated to a large size in order to tear the muscle fibers of the valve to weaken it. Patients undergoing balloon dilation run a slight chance of rupturing their esophagus during the treatment, a known complication that may require surgical correction. Balloon dilations are not as effective as surgery in giving long-term Achalasia relief and improvement in swallowing, but they generally provide Achalasia relief and improvement for a reasonable amount of time.

The most common operation used to treat Achalasia is the robotic Heller myotomy, a robotic procedure involving the severing of the LES muscle to alleviate difficulty swallowing, allow food and liquids to flow into the stomach. During the process, the LES is partially reconstructed to prevent severe reflux after surgery. Surgery has proven to be the most effective long-term treatment for Achalasia, and the majority of patients see almost immediate improvement in swallowing function.

Another procedure that can be used to treat Achalasia is the POEM or PerOral Endoscopic Myotomy. This procedure is performed completely endoscopically. In certain subtypes of achalasia, the POEM procedure is very effective at treating patients symptoms. It does come with some increased reflux compared to a Heller myotomy. If after testing and discussion with patients that are good candidate for the POEM procedure, Dr. Grandhige will refer them to a specific physician in the Tampa area who specializes in this form of therapy.

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