Achalasia of the Oesophagus

Achalasia is a rare disorder of the oesophagus (the tube leading to the stomach). It is characterised by obstruction at the junction between the oesophagus and the stomach. There is failure of the lower oesophageal sphincter to relax with swallowing, and weakening or absence of the normal muscular contraction (peristalsis) in the main part of the oesophagus.

Secondary achalasia may be caused by lymphoma, Chagas' disease, certain viral infections, eosinophilic gastroenteritis and neurodegenerative disorders. It may also be caused by gastric cancer that infiltrates the oesophagus, or it may predispose to oesophageal cancer.

Symptoms

Achalasia affects patients of all ages and both sexes, however it usually develops in middle life. Symptoms include difficulty in swallowing (dysphagia), chest pain and regurgitation. Dysphagia appears early and occurs with both solids and liquids. It is worsened by emotional stress and hurried eating.

Diagnosis

Achalasia is diagnosed by oesophageal motility studies that show loss of peristalsis (muscle contraction) in the body of the oesophagus and increased pressure in the lower oesophageal sphincter. Chest x-ray and upper gastrointestinal endoscopy may show some features that suggest diagnosis, but they are not diagnostic.

An endoscopy may also be done to exclude any secondary causes of achalasia, especially gastric carcinoma.

Treatment/Therapy

Nitrates and calcium channel blockers give good short term benefit, but their use may be limited by side effects.

Dilatation (widening by balloon) of the lower oesophageal sphincter can be done by endoscope and will improve symptoms in most patients. However, some patients may require more than one dilatation and those needing frequent dilatation are best treated surgically.

Another endoscopic procedure can be performed, where an injection of botulinum toxin into the lower oesophageal sphincter induces clinical remission, but late relapse is common.

Surgery may reduce pressure in the lower oesophageal sphincter.