Have you ever wondered what happens to the food that you swallow? Ideally, every bite of food you eat is swallowed and reaches the esophagus i.e. the long tube connecting your mouth to the stomach. The muscles that make up the esophagus are propelling the food downward until it reaches the bottom where it passes on to the stomach.

Sounds simple, right? But this might not be the case in achalasia, an esophageal disorder in which the food you swallow doesn’t make it to the stomach, at least not easily. No matter how much you try, the food keeps stuck in the food pipe and makes you feel like something is wedged in your throat. In some cases, the food may come back up and out of the mouth.

If this sounds familiar, it’s high time you familiarized yourself with achalasia, what causes it, and how to confirm and manage it to make your life easier.

An Overview 

Achalasia refers to a disorder of the esophagus that interferes with swallowing and transportation of food within the gut. As a rare disorder affecting 8 to 12 per 100,000 individuals worldwide, it is characterized by degeneration of the nerve cells in the esophagus for unknown reasons. As these nerve cells are destroyed, the following two problems occur interfering with swallowing:

The muscles lining the esophagus are unable to contract normally. As a result, the food you swallow does not propel through the esophagus into the stomach

The lower esophageal sphincter (LES) i.e., a band of muscles at the lower end of the esophagus fails to contract. This sphincter works as a guard and regulates the transportation of food from the food pipe to the stomach. In normal cases, it opens up as a response to the food and closes once the food has passed into the stomach to prevent back flow. With the disruption of the LES function, the food is unable to pass to the stomach and ends up coming back to the mouth in some cases.

Achalasia commonly affects people between 30 to 60 years and is more commonly seen in men than women. Despite being an uncomfortable and potentially life-changing condition, achalasia does have several modes of treatment that focus on decreasing the resistance in the esophagus.

Achalasia Symptoms

Achalasia typically presents with difficulty in swallowing (dysphagia) and a feeling like the food is still stuck in the throat. In some people, it may induce coughing and increase the risk of choking on food. Other symptoms of achalasia include:

• Unexplained weight loss
• Pain or discomfort in the chest
• Heartburn
• Dry mouth
• Dry eyes
• Intense pain after eating

Some people may also experience regurgitation or back flow of food into the mouth even after they have swallowed it. This sometimes leads to a false diagnosis of gastro-esophageal reflux disease.

What Causes Achalasia?

Because of the rarity, experts are not completely sure about the reason behind achalasia. However, certain risk factors that potentially increase your chances of developing the issue include the following:

• Injury to the spinal cord
• A recent viral infection
• Previous history of an autoimmune disease
• Advanced age
• Getting endoscopic sclerotherapy for bleeding veins

Further research is underway to determine the possible factors that contribute to its development and progression.

How To Tell If You Have Achalasia?

The rarity of achalasia can potentially delay and complicate the diagnosis since many professionals may not recognize the symptoms right away. To form a diagnosis, an expert will ask you about the following:

• Any problems with food regurgitation
• Trouble swallowing foods that seem to be worsening over time
• Chest pain
• Heartburn

Additionally, they may use one or more of the following approaches to confirm the diagnosis:

Endoscopy 

This procedure involves inserting a tube with a small camera at one end into the esophagus to visualize it and look for the symptoms. While only one-third of patients get a diagnosis with endoscopy, the technique helps rule out other possible conditions, such as peptic ulcers.

X-ray

A doctor may order an x-ray of the chest to check for any enlargement of the esophagus due to the entrapped food. Sometimes, it is combined with barium swallow which involves taking liquid barium prior to an x-ray to monitor how it moves down the food pipe.

Esophageal manometry

Also known as motility study, esophageal manometry involves passing a narrow tube into the food pipe through the nose. The tube measures the pressure in your esophagus as you swallow food. This process reveals how much of the esophageal muscles are working in addition to measuring the pressure at LES.

The choice and order of these diagnostic tests may vary, depending on your symptoms, personal medical history, and family history. While most doctors recommend getting an endoscopy first, esophageal manometry is commonly regarded as the most reliable of them.

Treating Achalasia

Several treatment options are currently available to manage the symptoms of achalasia. While it is impossible to reverse the nerve cell destruction in the esophagus of the patients, the proposed treatments usually improve symptoms and make the quality of life a lot better.

Most of the treatments for achalasia aim to weaken the muscles forming the lower esophageal sphincter so that it does not hinder the passage of food. This can be done mechanically or through drugs.

Medication for Achalasia

Nitrates and calcium channel blockers are the two main types of drugs used for managing the symptoms of achalasia. These drugs are available as oral pills that need to be placed under the tongue 10 to 30 minutes before having food.

Medications are the least invasive remedy for achalasia; however, they are mostly considered as ineffective, inconvenient, and full of side effects. Moreover, these drugs usually tend to become less effective with time due to which they are not considered the primary treatment modality for patients with achalasia.

Balloon Dilatation

Also known as pneumatic compression, this process involves using a balloon to open the LES. A collapsed balloon is placed in the LES of the patient, often using an x-ray as a guiding test. Once the balloon is placed accurately in its spot, the doctors inflate it abruptly to a large size which, in turn, tears the muscles forming the LES. The procedure is extremely effective in relieving dysphagia in almost two-thirds of the patients. However, some may continue to experience chest pain even after it. In many cases, the procedure needs to be repeated for proper relief.

Surgery

The surgery done for relieving the symptoms of achalasia is known as myotomy. It is an operation that targets the LES muscles and tends to weaken them by cutting their fibers. The most common technique for performing this surgery is known as Heller myotomy in which the muscles at the bottom of the esophagus and beginning of the stomach are cut. Previously performed as an open procedure with an incision in the abdomen, surgeons now perform it laparoscopically using a camera inserted through a very tiny incision.

Botulinum Toxin Injection

Botulinum toxin can temporarily paralyze the nerves signaling the LES to contract. As a result, the obstruction at the bottom of the esophagus can be relieved. The procedure is usually performed during endoscopy with the patient under sedation. The botulinum toxin is injected directly into the LES muscle through the lining of the esophagus.

It is important to understand that none of the treatments mentioned above can completely cure achalasia. Therefore, it is important to keep in touch with your health care provider and show up for regular follow-ups. The goal for these follow-ups is to catch and manage any recurrent symptoms of the disease as well as the ongoing treatment. Recognizing any such issues early on can prevent the symptoms from getting severe or complicating into a much worse disease, such as cancer.

Living with Achalasia – Lifestyle Changes

While the cause of achalasia remains unknown, it does seem to have treatment options to ease life. The following simple tips are encouraged to be followed to make your life with achalasia easier to manage:

• Eat slowly to avoid putting a load on the esophagus and LES.
• Make sure to chew every bite properly.
• Drink lots of water with meals. Try sipping it even when you are chewing food to facilitate its transport.
• Avoid eating too close to bedtime.
• Avoid eating food that may cause acid reflux.
• Prop your head to a 45-degree angle as you sleep.

The techniques mentioned above are not the cure for achalasia, although they may provide a small degree of relief to many people. If your symptoms do not improve with these tips and are worsening with each passing day, medical intervention is required.

Outlook

The outlook for achalasia generally varies and a lot of factors contribute to it. Achalasia does not affect life expectancy in any way. Hence, there are no long-term risks associated with it. Getting diagnosed in earlier stages of the disease helps you get timely treatment and manage the condition better. In some cases, patients require multiple treatments while in others, treatment often fails and needs to be changed to a different one.