Understanding Achalasia — And Why Persistent Difficulty Swallowing Should Never Be Ignored

Have you ever felt like food or drink isn’t going down the right way? Occasional swallowing trouble happens to many of us, but persistent dysphagia (difficulty swallowing) can signal an underlying medical condition that deserves attention. One important but often underrecognized cause is achalasia.

What is Achalasia?

Achalasia is a rare disorder in which the esophagus loses its ability to move food toward the stomach, and the lower esophageal sphincter (LES), a muscular valve at the bottom of the esophagus, fails to relax properly. As a result, food and liquids can back up, causing discomfort, malnutrition, and other complications.

Incidence and Prevalence:

Achalasia affects approximately 1 to 2 people per 100,000 per year, with a prevalence estimated around 10 per 100,000. It can occur at any age but is most commonly diagnosed between ages 30 and 60, and affects both men and women equally.

Key Symptoms of Achalasia

Progressive dysphagia to both solids and liquids, unlike many other conditions (like strictures or tumors) where difficulty starts with solids and progresses to liquids.

Regurgitation of undigested food, sometimes hours after eating.

Chest pain or discomfort unrelated to heart disease.

Weight loss and malnutrition.

Aspiration (inhaling food or liquids into the lungs), which can lead to serious infections like aspiration pneumonia.

Because the esophagus isn’t emptying properly, patients with untreated achalasia are also at a slightly increased risk for developing esophageal cancer (specifically, squamous cell carcinoma) over time, particularly if achalasia is longstanding and severe.

What Causes Achalasia?

The exact cause isn’t fully understood, but it appears to involve degeneration of the nerve cells (ganglion cells) within the esophageal wall. Some theories suggest an autoimmune reaction triggered by infection or genetic predisposition may play a role.

How Is Achalasia Diagnosed?

High-Resolution Manometry (HRM):

The gold standard for diagnosis, HRM measures pressure patterns and muscle contractions in the esophagus with great precision. Achalasia typically shows absent peristalsis and elevated LES pressure.

EndoFLIP (Endolumenal Functional Lumen Imaging Probe):

A newer technology that can be used during endoscopy to measure esophageal distensibility (stretchiness) in real time, helping to assess the severity of obstruction.

Barium Swallow (Esophagram):

An X-ray test where you drink contrast material to visualize esophageal narrowing and the classic “bird-beak” appearance of the LES.

Upper Endoscopy (EGD):

Done to rule out other causes like cancer or strictures, and occasionally reveals retained food and liquid in the esophagus.

Treatment Options

Although achalasia cannot be “cured,” treatments aim to relieve symptoms by improving LES relaxation and esophageal emptying:

Pneumatic dilation: Forcefully stretching the LES with a balloon.

Heller myotomy: A surgical procedure to cut the LES muscle fibers, often combined with a partial fundoplication to prevent reflux.

POEM (Peroral Endoscopic Myotomy):

A minimally invasive endoscopic version of Heller myotomy, where the muscle is cut internally without any external incisions.

Botox injections:

Botulinum toxin can be injected into the LES to relax it. This is typically reserved for patients who are poor candidates for surgery, as Botox effects are temporary (lasting about 3–6 months).

Medications:

Such as nitrates or calcium channel blockers, but these are often less effective and used mainly for patients who cannot undergo procedures.

Other Causes of Dysphagia to Consider

Not all dysphagia is caused by achalasia. Other important causes include:

Mechanical obstruction:

Esophageal cancer

Strictures from acid reflux or caustic injury

Schatzki’s rings

Neuromuscular disorders:

Stroke

Parkinson’s disease

Amyotrophic lateral sclerosis (ALS)

Inflammatory conditions:

Eosinophilic esophagitis (EoE)

Connective tissue diseases:

Scleroderma (affecting esophageal motility)

Typically, dysphagia to solids first suggests a mechanical obstruction, whereas simultaneous dysphagia to both solids and liquids (especially early in the disease course) suggests a motility disorder like achalasia.

Bottom Line:

Persistent trouble swallowing is not something to ignore. Whether the cause is achalasia or another condition, early diagnosis and treatment can protect your health and, in some cases, even save your life.

If you or someone you know is experiencing symptoms of dysphagia, consult your healthcare provider for a thorough evaluation.