Achalasia

What is achalasia?

Achalasia is a rare primary motor disorder of the oesophagus. The muscle waves that normally push food down (peristalsis) are absent, and the lower oesophageal sphincter (LES) does not relax enough to let food into the stomach. Guts UK and the wider literature put annual incidence at about 1 to 3 per 100,000 — uncommon, not a everyday cause of dysphagia.

It is not curable: treatments improve emptying but do not reverse the underlying neuromuscular change. Left untreated, progressive dysphagia, regurgitation, weight loss, and aspiration risk can follow.

Symptoms

• Progressive difficulty swallowing (dysphagia) to solids and liquids
• Regurgitation of undigested food or saliva
• Chest discomfort after eating
• Weight loss
• Night-time cough or chest infections from aspiration in some people

Symptoms can be mistaken for reflux (GERD), but acid-suppressing medicines do not treat achalasia. Early dysphagia can also overlap with functional dyspepsia pathways and with eosinophilic oesophagitis (EoE) — endoscopy with biopsy helps separate EoE.

How it is diagnosed

• High-resolution manometry — defines absent peristalsis and incomplete LES relaxation, and identifies subtype (types I–III; Chicago classification / UEG–ESNM)
• Barium swallow — classic “bird-beak” appearance in many cases
• Endoscopy — rules out obstruction and other mucosal disease (including EoE biopsy when indicated)

BSG guidance on oesophageal manometry and reflux monitoring supports appropriate use of these tests in specialist pathways.

Subtypes

UEG/ESNM guidelines describe three manometric subtypes (I–III). Subtype helps clinicians choose between dilation, POEM, and surgical myotomy.

Approaches people discuss

Care belongs in specialist centres. The options below are clinic pathways — not home treatments.

• Established Pneumatic dilation as a first-line option to stretch the LES and improve emptying. Sources: UEG/ESNM 2020; NHS; Guts UK.
• Established Peroral endoscopic myotomy (POEM) as a first-line endoscopic option; comparable efficacy to laparoscopic myotomy for many type I–II patients in guideline summaries. Sources: UEG/ESNM 2020.
• Established Laparoscopic Heller myotomy (often with a partial fundoplication) when surgery is chosen. Sources: UEG/ESNM 2020; NHS.
• Established Botulinum toxin injection into the LES for temporary symptom relief when more definitive therapy is unsuitable. Sources: UEG/ESNM 2020.
• Emerging Autoimmune or infectious triggers are hypothesised in some cases; this does not change first-line emptying treatments today. Sources: UEG/ESNM 2020.

What not to self-manage

These are cautions, not approaches people discuss:

• Do not treat achalasia like GERD — PPIs do not fix failed LES relaxation or absent peristalsis; manometry separates the two.
• Do not assume every dysphagia is achalasia — it is rare (about 1–3 per 100,000 per year). Rapidly progressive solid-food dysphagia, marked weight loss, or new dysphagia over age 50 needs urgent exclusion of malignancy first.
• Do not expect a cure — dilation, POEM, and myotomy improve emptying; they do not reverse the neuromuscular disease.
• Do not pursue dilation or POEM outside specialist pathways — both carry perforation risk and need experienced teams.

Long-term notes

UEG/ESNM notes a small increased long-term risk of oesophageal squamous cell carcinoma after achalasia. That is different from the Barrett’s/adenocarcinoma pathway linked to chronic reflux — see our Barrett’s oesophagus page for that separate story.