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Achalasia

Achalasia is a disorder that makes it hard to eat and drink normally. The disorder affects your esophagus, which is the swallowing tube that connects the back of your throat to your stomach. If you have achalasia, your esophagus does not sufficiently push food or liquid into your stomach. In addition, the ring of muscle that circles the lower portion of your esophagus does not relax enough to let food and liquid pass through easily. In fact, achalasia means "failure to relax."

Achalasia usually develops slowly, making it harder for you to swallow food and beverages. It's caused by loss of the nerve cells that control the swallowing muscles in the esophagus. Why these nerve cells degenerate, however, isn’t known. Although achalasia has no cure, treatments are available. Achalasia affects about 2,000 people in the U.S. every year.

Symptoms

Symptoms of achalasia develop gradually. Over time, as the esophagus becomes wider and weaker, you may have these symptoms:

  • Difficulty swallowing food, a condition called dysphagia

  • Food or liquid flowing back up into your throat, or regurgitation

  • Waking up at night from coughing or choking because of regurgitation

  • Heartburn

  • Chest pain or pressure

  • Weight loss 

Who's at risk

Achalasia can develop at any age, but it occurs most often between ages 30 and 60. Men and women are equally at risk. Scientists don’t know exactly why this loss of muscle control in the lower esophagus happens, but risk factors may include:

  • Genes you are born with

  • A disordered immune system that attacks the nerve cells in your esophagus

  • The herpes simplex virus or other viral infections 

Diagnosis

If your doctor suspects achalasia from your symptoms, he or she may order three tests to confirm your diagnosis:

  • Endoscopy. This is an outpatient procedure during which a flexible telescope is passed through your mouth to examine your esophagus and the valve that opens into your stomach. This valve is called the lower esophageal sphincter (LES).

  • Esophogram. This is a special type of X-ray that takes pictures of your esophagus while you swallow a thick contrast material called barium. Signs of achalasia that your doctor looks for are widening of the esophagus, incomplete emptying, and tightness of your LES.

  • Manometry. This is an outpatient procedure during which a pressure-measuring tube is passed through your nose into your esophagus. Pressure measurements are taken as you swallow sips of water. This test may show weak and uncoordinated muscle contractions and pressure buildup at your LES.  

Treatment

No treatment can restore normal esophageal movement, but treatments can help relieve your symptoms, open up your LES to improve emptying of your esophagus, and prevent complications. You may also need repeat treatments.

These are common treatments:

  • Pneumatic dilation. This is an outpatient procedure done under anesthesia. While your doctor looks into your esophagus through an endoscope, an air-filled balloon is passed through the valve between the esophagus and stomach and then inflated. You may need more than one treatment to get relief.

  • Botox injection. Botox is a medication that can paralyze muscles. Botox can be injected into the muscles that control your LES to relax the valve opening. This procedure is also done during endoscopy, but you don’t need to be asleep. The results usually wear off in three months to one year, so the procedure may need to be repeated.

  • Surgery. Surgery to open your LES is called myotomy. During myotomy, the muscles of that valve are cut. This type of surgery usually provides long-term relief from achalasia symptoms.

Complications

Although you can’t prevent achalasia, treatment can prevent long-term complications. Possible complications include:

  • Aspiration pneumonia. This type of pneumonia may be caused when food or liquids in your esophagus back up into your throat and you breathe them into your lungs.

  • Esophageal perforation. This complication may occur if the walls of your esophagus become weak and distended. Perforation may also occur during treatment. Esophageal perforation may cause a life-threatening infection.

  • Esophageal cancer. People with achalasia are at higher risk for esophageal cancer.  

When to call the doctor

Call your doctor if you have any questions about your medications or treatment. Let your doctor know right away if you have any of these symptoms:

  • Increased difficulty swallowing

  • Worsening regurgitation, especially if you are waking up coughing or choking at night

  • Symptoms of infection such as chills or fever

  • Chest pain or difficulty breathing 

Living with achalasia

Achalasia is a long-term disease, so it's important to learn as much as you can about it and work closely with your medical team. Your health providers will need to follow you on a regular basis, usually once or twice a year, even after symptoms have been controlled. Keep all your appointments. Your doctor may also want to repeat endoscopy and an esophogram.

Here are some lifestyle changes that may help you if you have symptoms of dysphagia or regurgitation:

  • Stop smoking.

  • Avoid foods or beverages that give you heartburn.

  • Drink plenty of fluid when eating and chew your food well.

  • Eat more frequent, smaller meals.

  • Avoid eating for three hours before you go to bed.

  • Avoid sleeping in a flat position by elevating the head of your bed several inches.

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