Achalasia is a condition that affects how the oesophagus (also often called the gullet) works, and causes symptoms related to eating and drinking. The oesophagus is a muscular tube that runs from the back of the throat through the chest into the stomach. When you swallow food or drink, this tube normally contracts (or pushes) what you have swallowed downwards into the stomach. In addition, a small ring of muscle at the bottom of the oesophagus just above the stomach (shown as the gastro-oesophageal junction in the picture below) relaxes to let the food and drink through. In achalasia, the muscles in the oesophagus do not work properly. The ring of muscle at the bottom of the oesophagus does not relax as it should, making it difficult for food and drink to get through into the stomach. In addition, the whole of the oesophagus above this stops contracting (or pushing) in the normal way.

Image credit: Cancer Research UK Uploader, 2016

Different symptoms that patients with achalasia can experience are explained below.

Difficulty swallowing

Patients often experience difficulty eating and drinking. The medical term for this is dysphagia. This means that food or drink may get stuck on the way down, which can sometimes be felt in the chest behind the breast bone. This can vary day-to-day, so the same food or drink can be more or less of a problem on different days or weeks.

Heartburn or pain

Patients may experience a burning or achy sensation in the middle of the chest behind their breast bone or in the upper part of the abdomen or tummy. Sometimes this can be severe and people report feeling pain in this area. However, this is a very common symptom in people in general, not just people with achalasia, with up to 20% of the population suffering indigestion symptoms each week.

Pain on swallowing

Patients may experience pain in the middle of the chest, behind the breast bone, when they swallow food or drink. The medical term for this is odynophagia. In addition some people may get severe pains from spasms of the oesophagus. Others get milder symptoms that are more like heartburn.

Regurgitation and/or vomiting

Food and drink that gets stuck in the oesophagus and cannot easily enter the stomach may come back up, either as regurgitation or vomiting.

Weight loss

It can be very difficult to eat and drink normal amounts so some people lose weight.

A number of different tests can be performed to assess people with achalasia, to look for other common causes of the same symptoms and make a definite diagnosis.

Upper GI endoscopy

The first test to investigate difficulty in swallowing is usually an upper GI endoscopy (often referred to as an OGD). This is a common procedure involving the insertion of a thin tube with a camera on the end through the mouth into the oesophagus, stomach and first part of the small bowel called the duodenum. This test is important to look for signs of achalasia as well as to look for other problems such as acid damage or oesophageal cancer. It is a very routine procedure, but as with any test there are benefits and risks, even though the risks are very low. More information on this procedure, its benefits and risks are available here.

Contrast swallow

This test may also be called a barium swallow and is often combined with a meal test to examine the stomach as well as the oesophagus. It involves drinking some fluid (called barium) and having x-ray pictures taken of the fluid going down the oesophagus into the stomach. This is a good test of how the oesophagus squeezes and is very helpful in making a diagnosis of achalasia (see figure 1).

Figure 1. Appearance of achalasia on barium swallow. Source: UHBW NHS Foundation Trust, 2021.

pH and manometry

These two tests (pH testing and manometry) are often combined to assess a range of symptoms. They involve passing a fine tube through the nose into the oesophagus, then doing a series of swallowing tests to measure how the oesophagus works (the manometry part of the test). A tube is then left in place for 24 hours and you go home with this before having it removed the following day (pH testing). During this period, you can record symptoms that you experience which can then be looked at together with measurements from the tube.

The options for treatment include lifestyle modification, endoscopic treatment and surgery.

Lifestyle modification

If your symptoms are mild or the risks of treatment are considered to be very high, achalasia may be best managed with changes in diet to maintain enough food and drink intake, and minimise symptoms. You may be referred to a dietitian to help with this.

Endoscopic treatment

One common treatment for achalasia is to perform an upper GI endoscopy and use a balloon to stretch the ring of muscle at the bottom of the oesophagus, to open it up and allow food and drink to pass through more easily. This is usually done in the endoscopy room with some sedation and pain relief, and you can normally go home the same day provided you have someone to take you home and stay with you overnight. There are some risks associated with the procedure, such as a chance of bleeding or making a hole in the oesophagus (called a perforation). Your doctor can explain the risks and benefits of this treatment in more detail. At University Hospitals Bristol and Weston, we do not provide balloon dilation service for achalasia, so if you would like to have this treatment, please discuss it with your doctor who can refer you to another hospital (such as Southmead Hospital).

Another endoscopic treatment that can be performed is the injection of a drug (botulinum toxin, or Botox) into the ring of muscle between the oesophagus and stomach. This injection can help this muscle to relax, allowing food and drink to pass through more easily. However, the injection wears off after approximately 3 months, so it is not considered to be an effective long-term treatment. However, it may provide your surgeon with an indication of how effective an operation is likely to be.

Surgery

An operation is the other main way of treating achalasia. The operation is called a Heller's cardiomyotomy. This is done under a general anaesthetic, usually by key hole surgery, and involves a long cut in the muscle of the oesophagus, starting at the top of the stomach and going upwards along the oesophagus. This opens up the ring of muscle at the bottom of the oesophagus and allows food and drink to pass more easily. Many surgeons combine this operation with a form of anti-reflux operation called a fundoplication. As with endoscopic balloon treatment, there are some risks, including bleeding and making a hole in the oesophagus or stomach. Your doctor can explain to you more about the benefits and risks of the operation.

Here are some useful links to other sources of information on achalasia. However, as these are external websites, we are not responsible for the accuracy of any content which may change over time.

NHS website:

https://www.nhs.uk/conditions/achalasia/#

Guts UK - digestive system charity:

https://gutscharity.org.uk/advice-and-information/conditions/achalasia/

Oeosphageal Patients Association - achalasia support group subpage:

https://www.opa.org.uk/achalasia.html