Achalasia

Achalasia is a rare condition that makes it difficult for the gullet (oesophagus) to carry food and drink into the stomach.

Normally, during swallowing the muscles of the gullet contract downwards and the valve where the gullet joins the stomach — the lower oesophageal sphincter — relaxes to let food pass into the stomach.

In achalasia the normal contractions of the gullet are disturbed and this valve cannot relax enough. As a result food and liquids struggle to pass into the stomach and begin to collect in the gullet. Over time the gullet may widen.

The exact cause of the disease is not fully known. It is currently thought that damage to some of the nerve cells controlling the movements of the gullet plays an important part.

Signs and symptoms

The symptoms of achalasia usually appear gradually and may become more marked over time. The most common complaints are:

• Difficulty swallowing: trouble swallowing both solid food and liquids
• A feeling that food is stuck in the chest
• Swallowed food or liquid coming back up into the mouth
• Bitter or undigested food coming into the mouth, especially when lying down at night
• Chest pain or a feeling of pressure in the chest
• Coughing at night
• Food coming into the throat or mouth from sleep at night
• Weight loss
• Belching and bloating

In some patients the food and liquid collecting in the gullet can pass into the lungs. This can cause coughing, especially at night, repeated chest infections and, rarely, pneumonia.

How is the diagnosis made?

A single test may not always be enough to diagnose achalasia. Several examinations are usually assessed together.

1. Endoscopy

The gullet and stomach are examined with a thin camera passed through the mouth.

Endoscopy matters less for showing achalasia itself than for excluding other diseases of the gullet, and in particular any condition that could be narrowing the gullet or the entrance to the stomach. It becomes especially important where complaints have begun recently in later life, or where there are alarm findings such as rapid weight loss.

2. Oesophageal manometry

This is one of the most important tests in diagnosing achalasia. A thin catheter is used to measure how the gullet works during swallowing and how far the valve at the entrance to the stomach relaxes.

Manometry also helps to classify achalasia as Type 1, Type 2 or Type 3. This classification matters in choosing the treatment to be used.

3. Barium swallow

The patient drinks a liquid containing barium and X-ray images are taken. Whether the gullet has widened, and how the passage into the stomach behaves, are assessed.

4. FLIP

Where the diagnosis is not clear, an advanced method called FLIP (functional lumen imaging probe) may be used. It helps to assess how far the gullet and the region at the entrance to the stomach are able to open.

Methods of treatment

Although the cause of achalasia cannot be removed completely, there are today effective treatments that markedly reduce the difficulty in swallowing in the great majority of patients. The main aim of treatment is to relax or open the tight region at the entrance to the stomach, so that food passes into the stomach more easily.

POEM

POEM (peroral endoscopic myotomy) is today one of the important treatment options in achalasia. An endoscope passed through the mouth is used to enter the gullet, and the excess muscle tissue at the entrance to the stomach is cut from within to ease the passage. One of its important advantages is that no incision is made in the abdomen.

POEM is the treatment that comes to the fore in most current approaches especially in patients with what is called Type 3 achalasia, where spasm in the gullet is prominent. The 2024 AGA expert recommendations and the updated SAGES guideline published in 2025 also name POEM as the particularly preferred option in Type 3 achalasia.

The chance of reflux developing after POEM may be higher than with some other treatments. It is therefore important to follow the patient up for reflux after the procedure and, where needed, to use medicines that reduce stomach acid.

Heller myotomy

Heller myotomy is an operation, usually performed by keyhole surgery, that surgically relaxes the muscles at the entrance to the stomach.

In most patients an additional procedure called fundoplication is carried out during the same operation, to prevent reflux from developing afterwards.

In choosing between POEM and Heller myotomy, the patient’s age, general health, the type of achalasia, the structure of the gullet and the patient’s own preferences are assessed together.

Pneumatic dilatation

In this method a balloon is placed at the region where the gullet joins the stomach and inflated in a controlled way, so that the tight muscles relax.

It is an effective treatment and may need to be repeated in some patients. Alongside POEM and the surgical options, it remains an important alternative today.

Botox

Botulinum toxin (Botox) is injected into the muscle at the entrance to the stomach during endoscopy; the aim is to make that muscle relax.

It is generally not a lasting treatment. Because its effect can wear off over time, it is preferred mainly in patients who could not withstand surgery or the other interventional treatments.

Medicines

Some medicines can relax the muscle at the entrance to the stomach temporarily. But their effects are limited and they are generally not preferred as the main treatment of achalasia today.

Which treatment is better?

No single treatment is the best option for everyone. In the current approach it matters in particular whether the achalasia is Type 1, Type 2 or Type 3.

• Types 1 and 2: POEM, Heller myotomy and pneumatic dilatation are all effective options.
• Type 3: POEM comes to the fore, especially in patients where the spasm affects a longer segment of the gullet.
• In patients of advanced age or with other serious health problems, options carrying lower risk may be considered.
• In patients who have been treated before but whose complaints have returned, a different method of treatment may come into question.

For this reason the decision on treatment should not be made by looking at the name of the disease alone; the manometry result, the width of the gullet, the patient’s age and general health should be assessed together.

Does achalasia go away completely?

Achalasia is a chronic disease. There is at present no treatment that completely removes the nerve damage underlying it.

Even so, modern methods of treatment can bring marked improvement in swallowing difficulty and other complaints in the great majority of patients.

In some patients symptoms may reappear over the years after treatment. It is therefore important that patients are followed up for their complaints even where treatment has succeeded.

It should be remembered in particular that reflux can develop after POEM or Heller myotomy. Patients with symptoms of reflux, or in whom reflux is found at endoscopy, are given appropriate treatment and follow-up.

In short

Achalasia is a treatable disease, although the disease itself cannot be removed completely. Thanks to effective treatments such as POEM, Heller myotomy and pneumatic dilatation, patients’ quality of life today usually improves markedly.

People with difficulty swallowing — especially those who struggle with both solids and liquids, or who feel food sticking in the chest — are advised to consult a gastroenterologist.