Achalasia and other Motility Disorders of the Oesophagus

What is it?

These conditions are reasonably uncommon. It is best to start with how the oesophagus works. Most of the oesophagus is controlled by involuntary means. That is, we can't change the function of it. The way food is propelled into the oesophagus is through a process called peristalsis. That means the muscle propels the food in a coordinated way into the stomach. These coordinated waves can be seen on a test called manometry. The oesophagus also has a valve at its lower end that opens to allow food through. This typically relaxes when the peristalsis is occurring and then closes as the food hits the stomach.

Achalasia is a condition that affects 1/100,000 people, therefore it is uncommon. In achalasia, the waves that propel food into the stomach or peristalsis are absent therefore foods travels very slowly into the stomach. In addition to this, the lower valve fails to relax and therefore there is a hold up of food at the lower end of the oesophagus. This results in the sensation of food sticking or in medical terms dysphagia. Food may sit in the oesophagus so long it is regurgitated when lying or even when standing. Achalasia often starts with chest pain and reflux progressing to dysphagia. There are a range of conditions that may mimic achalasia or even be achalasia in its early form. We call these motility disorders. The most common one is the nutcracker oesophagus. This is the result of very high uncoordinated contractions along the oesophagus. This results in chest pain and dysphagia. Some people believe this is a variant of achalasia and may continue onto achalasia later.

How do we diagnose achalasia?

The gold standard is oesophageal manometry. This is a test where a fine tube is placed into the nose and then into the oesophagus. It measures pressures in the oesophagus with a series of swallows. Barium swallow is also helpful. Gastroscopy is of limited value but may show a pop as the scope goes through the tight valve. You may also see food in the oesophagus.

Treatment

There are a number of ways to treat this condition. Medical treatment includes stretching the valve with a gatroscope and balloon or injecting with botox. Both of these attempt to relax the valve but are not a permanent solution. They may make surgery harder in the future therefore you need to think carefully if considering this option. Surgery is the best chance to fix this disorder. It is a keyhole operation called a Hellers myotomy. This involves cutting the lower valve allowing permanent relaxation. It is usually combined with a fundoplication to prevent reflux after cutting the valve. Although it is not perfect, you should be able to eat solids and liquids easily. Please remember that botox and balloon dilatation will make survey more difficult. The treatment of nutcracker oesophagus is more troublesome and generally is limited to medical management with a drug called nifedipine. Sometime balloon dilatation may help.