Achalasia

Achalasia is a relatively rare disorder of the smooth muscle of the esophagus. The esophagus is a muscular tube that carries food and liquids from the mouth to the stomach. Achalasia makes it difficult for food and liquid to pass into the stomach from the esophagus.

At the bottom of the esophagus where it meets the stomach is a muscle called the lower esophageal sphincter (LES). When not swallowing, the LES remains closed to keep food, liquid, and stomach acid from moving back into the esophageal tube. When swallowing, nerve signals tell muscles to contract to push food down the esophagus (an action called peristalsis), and allow the LES to open.

In people with achalasia, the nerve cells in the lower esophageal tube and the LES do not work correctly. This results in:

• Uncoordinated peristaltic muscular activity
• Failure of the LES to open completely

While achalasia is associated with the loss of nerve cells in the esophagus, the cause of this process is unknown.

A risk factor is something that increases your chances of getting a disease or condition. Because the exact cause of achalasia is unknown, risk factors are unknown.

Symptoms of achalasia begin to occur between the ages of 25 and 60. Symptoms rarely develop in children. Symptoms tend to be mild at first, and then grow worse over months or years. The main symptom is difficulty swallowing solids and, as the disorder progresses, liquids.

Other symptoms may include:

• Discomfort or pain in the chest (under the breastbone, especially after meals)
• Coughing, especially when lying down
• Heartburn
• Weight loss (as the disorder progresses)
• Vomiting or regurgitating food or liquids; in some people this occurs during sleep. This can result in inhalation

of food particles or liquid, which can lead to aspiration pneumonia and other respiratory infections.

The doctor will ask about your symptoms and medical history and perform a physical exam. Tests may include:

• Manometry – a tube is inserted down the throat to test the pressure in the esophagus and the stomach when swallowing
• Esophagography – x-rays are taken of the esophagus while you swallow barium (a thick liquid that shows up on x-rays)
• Endoscopy – a thin, lighted tube is inserted down the throat to examine the lining of the esophagus and stomach

The goal of treatment is to make it easier for the LES to open. Treatment may include:

Pneumatic dilation – this treatment stretches the LES muscle. A thin tube is inserted into the throat. At the end of this tube is an un-inflated balloon. Once the tube reaches the point of the LES muscle, the balloon is inflated. Its high success rate makes pneumatic dilation the primary treatment in most patients, although the procedure may need to be repeated.

Botulinum toxin – tiny amounts of botulinum toxin are injected into the LES. Botulinum causes the LES to relax, which makes it easier to open. Since the effect is temporary, repeat injections are almost always needed.

Surgery – small incisions are made in the LES to help it to relax. This is called Heller cardiomyotomy surgery. This can usually be performed via laparoscopy, making it a relatively minor surgical procedure. Because the LES is partially cut, about 15% of patients experience gastroesophageal reflux symptoms after this surgery.

Medication – in mild cases, certain medications may help relieve symptoms temporarily. Drugs that reduce LES pressure. include:

• Nifedipine
• Nitroglycerin

There are no guidelines for the prevention of achalasia because the cause is usually not known.