Achalasia

Achalasia is a rare disease of the muscles of the oesophagus. The term means "failure to relax". Normally food is moved from the mouth and down the oesophagus to the stomach by a series of muscular contractions known as peristalsis.  As food reaches the end of the oesophagus, the sphincter relaxes and opens briefly allowing food to pass into the stomach to be digested.

In achalasia, the muscular layer of the oesophagus loses the ability to move food along and the sphincter fails to relax and open properly, thus restricting the passage of food into the stomach. As a result patients have difficulty in swallowing both solid and liquid food and suffer from regurgitation and sometimes chest pain.

The complications of achalasia include weight loss due to difficulties with swallowing and pneumonia caused by regurgitated food and liquid entering the lungs. Some patients experience chest pain and bouts of coughing when lying down.

Due to the similar symptoms, achalasia can be mistaken for other common disorders such as hiatus hernia, heartburn and gastro-oesophageal reflux disease (GORD). Diagnosis is usually by:

• oesophageal manometry. A thin tube is inserted through the nose into the oesophagus and the strength of the muscle contractions during swallowing is measured.
• barium swallow.  The patient swallows a barium meal and, using continuous x-ray, the flow of liquid down the oesophagus is monitored.  Normal peristaltic contractions are not seen.  Instead, the flow into the stomach appears severely restricted and the oesophagus may also be enlarged due to gradual stretching over time by retained food.

Four main treatments are currently available, although none cures the condition completely. The effect of each is to reduce the pressure in the sphincter to allow food to pass more easily into the stomach:

• oral medications
• stretching or dilation of the lower sphincter
• keyhole surgery to cut along the sphincter to relax the muscles.   This procedure helps 90% of patients but requires being on a soft diet for several weeks after surgery to stop reflux occuring.
• injecting botulinum toxin (Botox) into the sphincter to inhibit muscle contractions.

Even after successful treatment, swallowing may still deteriorate over time.  Patients are advised to eat slowly, drink plenty of fluids and avoid foods that aggravate reflux such as alcohol, caffeine, chocolate, citrus and mint. Yearly check-ups are recommended with repeat stretching of the sphincter or keyhole surgery as needed.  If untreated, achalasia may develop into Barrett's oesophagus.