Achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and the lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis.
Achalasia is characterized by:
- Difficulty swallowing
- Chest pain
Achalasia is diagnosed by:
- Esophageal manometry
- Barium swallow radiographic studies
Achalasia affects about one person in 100,000 per year. Prevalence of the condition is 10 in 1,000,000 individuals. There is no gender predominance for the occurrence of the disease.
Treatment of achalasia includes:
- Medication - sublingual nifedipine significantly improves outcomes in 75% of people with mild or moderate disease.
- Lifestyle Changes - Both before and after treatment, achalasia patients may need to eat slowly, chew very well, drink plenty of water with meals, and avoid eating near bedtime. Raising the head of the bed or sleeping with a wedge pillow promotes emptying of the esophagus by gravity. After surgery or pneumatic dilatation, proton pump inhibitors are required to prevent reflux damage by inhibiting gastric acid secretion, and foods that can aggravate reflux, including ketchup, citrus, chocolate, alcohol, and caffeine, may need to be avoided.
- Pneumatic Dilatation - In balloon (pneumatic) dilatation, the muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincters. Surgeons who specialize in achalasia have performed many of these forceful balloon dilatations and achieve better results and fewer perforations.
- Surgery - Heller myotomy helps 90% of achalasia patients. It can usually be performed by a keyhole approach or laparoscopically. The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down into the stomach a little way. The esophagus is make of several layers, and the myotomy cuts only through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. A partial fundoplication or "wrap" is generally added to prevent excessive reflux, which can cause serious damage to the esophagus over time.
Follow up - even after successful treatment of achalasia, swallowing may still deteriorate over time. The esophagus should be checked every year or two.