Achalasia

Achalasia is an uncommon disorder of esophageal motility. It is characterized by decreased or absent motility in the body of the esophagus along with relaxation of the lower esophageal sphincter.

Causes

The exact cause of this disorder is not known. There are many theories as to why it occurs, including inflammation, infection, and very rarely, the cause is considered to be familial.

Symptoms

Patients with achalasia may suffer symptoms for a long time before being diagnosed. Because this disease is progressive, many patients adapt their dietary habits and live with achalasia for a long time before seeking attention. The most common symptom is dysphagia or difficulty swallowing both liquids and solids.

Regurgitation of recently digested or partially digested food, particularly at night, occurs in many patients. Some patients may have a cough and choking due to aspiration of food particles into their airways. Patients may also have chest pain or weight loss due to poor dietary intake.

Diagnosis

Many different tests are used to diagnose this disorder. Diagnosis is most often made on an upper gastrointestinal series X-ray. All patients should undergo an upper endoscopy to rule out other esophageal conditions such as cancer. The “gold standard” test for diagnosis is manometry. This test can document the motility of the esophagus and measure the pressure at the lower esophageal sphincter.

Treatment / Surgery

Treatment consists of medical therapy, pneumatic dilatation, Botox injection and surgery.

• Medical therapy consists of medications such as calcium channel blockers or beta blockers. These do not provide consistent, long-lived relief of symptoms. Therefore, medical therapy is reserved for patients who are unable or unwilling to undergo other treatment methods.
• Pneumatic dilatation is the most common initial treatment. About 70 percent of patients will have good or excellent relief after dilatation. However, the results may not be long-lived and dilatation may need to be repeated. The dilatation procedure carries a 1 to 2 percent morbidity rate from rupture of the esophagus.
• Botox injection into the lower esophageal sphincter muscle provides symptom relief in about 60 percent of patients. However, this relief lasts for a shorter period of time and needs to be repeated. Frequent Botox injections may make subsequent surgery more difficult.
• The operation to treat achalasia is called an “esophagocardiomyotomy” or “Heller myotomy." The surgery can be done laparoscopically utilizing 5 to 6 tiny incisions in the abdomen. Patients can recover faster with this laparoscopic approach. It may not be appropriate for all patients and some may require a laparotomy (one larger abdominal incision) or sometimes a thoracotomy (incision on the chest, in between the ribs). Over 75 percent of patients will have good to excellent long term results with surgery.