Achalasia

Overview

Achalasia is a rare condition that affects the esophagus, the tube that carries food and liquid from your mouth to your stomach. In achalasia, the muscle at the lower end of the esophagus does not relax properly, so food and drink have trouble passing into the stomach. Over time, the esophagus can also lose its normal squeezing action, which makes swallowing even harder.

Achalasia is rare. Specialist services suggest it affects about 1 in 100,000 people each year, although the exact number may be higher because some cases go undiagnosed for a while.

Achalasia can happen at any age, including in children, but it is most often diagnosed in adults between the ages of 25 and 60. It affects men and women in roughly equal numbers.

Symptoms

Common symptoms

• Difficulty swallowing food or liquids, often feeling like food is stuck in the chest or throat
• Bringing up undigested food or foamy liquid, especially at night
• Chest pain or a burning feeling that can be mistaken for heartburn
• Coughing or choking, especially when lying down
• Heartburn that does not go away with usual lifestyle changes
• Unintentional weight loss because eating becomes difficult

Symptoms in children

• Feeding difficulties or very slow eating
• Frequent vomiting after meals
• Poor weight gain or failure to grow as expected
• Repeated chest infections or wheezing caused by food or liquid going into the lungs

Symptoms in older adults

• Trouble swallowing, sometimes with coughing during meals
• Regurgitation of food minutes or hours after eating
• Weight loss and reduced appetite
• Chest discomfort or heartburn-like symptoms that may be blamed on ageing or acid reflux

Causes

Main causes

• The exact cause of achalasia is not fully understood.
• Experts believe the immune system may mistakenly attack the nerve cells in the wall of the esophagus.
• Damage to these nerves means the lower esophageal sphincter remains tight and does not open when you swallow.

Risk factors

• Age: most cases are diagnosed between 25 and 60 years old.
• Family history: a small number of cases appear to run in families.
• Autoimmune conditions: achalasia may be more common in people with certain autoimmune diseases, although the link is not fully clear.

When to see a doctor

See a doctor urgently if:

• If you have sudden, severe chest pain or are unable to swallow any fluids, call your local emergency number or go to an emergency department immediately.
• If you are vomiting blood or have black, tarry stools, seek urgent medical help the same day.
• If you have a high temperature and a new cough, especially after a choking episode, get urgent care.

Book a routine appointment if:

• See your GP or family doctor if you have had difficulty swallowing for more than a few weeks.
• Make an appointment if you are losing weight without trying.
• See a doctor if food or drink frequently comes back up, or if you have persistent chest discomfort after eating.

Diagnosis

Achalasia is usually diagnosed by a specialist in digestive conditions, called a gastroenterologist. The diagnosis is based on your symptoms, a physical examination, and special tests that look at how your esophagus works.

Tests that may be done

• Barium swallow: you swallow a chalky liquid while X-rays are taken to see how it moves down the esophagus.
• Upper endoscopy: a thin, flexible tube with a camera is passed through your mouth into the esophagus to check for blockages or other problems.
• Esophageal manometry: a small tube measures the pressure and squeezing movements inside the esophagus, and checks whether the lower valve relaxes when you swallow.

What to expect at your appointment

Most tests are done as an outpatient or day-case visit. You may be asked not to eat or drink for a few hours beforehand. Some tests feel uncomfortable but are usually not painful. Afterward, your specialist will explain the results and discuss the best next steps with you.

Treatment

Treatment for achalasia cannot repair the damaged nerves, but it can help open or relax the lower part of the esophagus so food and drink can pass through more easily. The right treatment depends on your age, overall health, and how severe your symptoms are.

Self-care at home

• Eat small, frequent meals instead of large ones.
• Chew food thoroughly and take your time during meals.
• Drink plenty of fluid with meals to help food move down.
• Sit upright while eating and stay upright for at least 1 to 2 hours afterward.
• Raise the head of your bed slightly to reduce regurgitation at night.
• Avoid eating too close to bedtime.

Medical treatments

Medicines are not a long-term cure for achalasia and are rarely used alone. The main treatments are procedures done through an endoscope or by surgery. These include stretching the lower esophageal sphincter with a balloon, injecting a muscle-relaxing substance directly into the sphincter, and cutting or dividing the sphincter muscle. Your specialist team will explain the benefits, risks, and expected recovery for each option. Some people need more than one procedure over time.

When is surgery considered?

Surgery called myotomy is often recommended for younger patients or for people who have not improved after endoscopic procedures. It is usually performed through small keyhole incisions. A newer endoscopic procedure called POEM may also be an option, depending on your individual case.

Living with this condition

Living with achalasia means paying a little more attention to mealtimes. Some people find that certain textures, temperatures, or large meals make symptoms worse. Keeping a simple food diary can help you notice patterns and make adjustments without losing important nutrients.

Lifestyle tips

• Keep your weight stable with nutrient-rich foods and snacks if you are losing weight.
• Stay active with gentle exercise, such as walking; this supports your overall health and appetite.
• Take small sips of water throughout the day and keep fluids within reach at meals.
• If you smoke, consider getting support to stop, as smoking can make chest and reflux symptoms worse.

Diet and exercise

There is no single achalasia diet. Most people do best with soft, moist foods eaten slowly and often. If swallowing is difficult, a dietitian can suggest smooth or pureed meals that still contain enough energy and protein. Gentle exercise like walking or swimming is safe and can help you feel well, but avoid bending or heavy lifting right after eating.

Mental health and emotional wellbeing

Difficulty swallowing can feel stressful, embarrassing, or frightening, especially in social settings. It is normal to feel frustrated or low at times. Talk to your doctor or care team if the emotional side feels heavy. And if you ever feel in crisis or have thoughts of harming yourself, please contact your local emergency number or mental health crisis service right away.

Prevention

There is currently no known way to prevent achalasia, because it is not caused by diet, exercise, or lifestyle choices. The best you can do is notice symptoms early and see a doctor promptly so the condition can be treated before complications develop.

Vaccines

There is no vaccine against achalasia.

Screening programmes

There is no routine screening test for achalasia in people without symptoms. If you have a family history of achalasia and you notice swallowing problems, tell your doctor.

Complications

If left untreated

• Weight loss and malnutrition because food cannot pass into the stomach properly.
• Aspiration pneumonia, a lung infection caused by inhaling food or liquid into the airways.
• Inflammation or widening of the esophagus over time.
• A very small increased risk of cancer of the esophagus after many years, which is why long-term monitoring is important.

Long-term outlook

Achalasia is a lifelong condition, but it is manageable. Most people improve significantly with treatment, and many can eat normal foods again with simple adjustments. You may need the occasional repeat procedure, but with regular follow-up and a good care plan, most people live full and active lives.

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