Achalasia and swallowing disorders explained

What achalasia is

The oesophagus, or gullet, is the muscular tube that carries food and drink from the throat down to the stomach. Normally its walls squeeze in a coordinated wave to push food down, and a ring of muscle at the bottom, the lower valve, relaxes to let food into the stomach. In achalasia, the nerves that control this muscle stop working properly. The wave of squeezing is lost, and the lower valve stays too tight and will not open fully. As a result, food and drink pile up in the gullet instead of passing smoothly into the stomach. Achalasia is uncommon and usually comes on slowly over months or years, which is one reason it can take time to be recognised. Its exact cause is not fully understood, but it is not something a person has done wrong.

Symptoms to recognise

The main symptom of achalasia is difficulty swallowing that slowly gets worse, often affecting both solid food and liquids from early on, which is a useful clue. People may feel food sticking behind the breastbone and have to wash it down, eat slowly, or change what they eat. Bringing back undigested food or saliva, especially when lying down at night, is common and can cause coughing or a sensation of choking. Chest discomfort, heartburn-like symptoms, and gradual weight loss can also occur. Because these features overlap with other conditions such as reflux, achalasia is sometimes mistaken for indigestion at first. Any persistent difficulty swallowing, food sticking, or unexplained weight loss should always be checked, because it needs investigation to find the cause and rule out more serious problems.

Other causes of swallowing problems

Achalasia is only one reason swallowing can go wrong. Difficulty swallowing can come from a narrowing of the gullet caused by long-standing acid reflux, from problems in the throat, or from conditions affecting the nerves and muscles such as after a stroke or with some neurological diseases. Importantly, difficulty swallowing can also be a warning sign of cancer of the gullet or stomach, particularly when it comes on over a few weeks, mainly affects solid food, or is accompanied by weight loss. This is exactly why new or worsening swallowing problems are taken seriously and investigated promptly rather than being put down to age or indigestion. Getting checked does not mean something sinister is present, but it makes sure serious causes are found or safely ruled out early.

How it is diagnosed

If you have persistent difficulty swallowing, your GP will usually refer you for tests, often quickly. A common first investigation is an endoscopy, in which a thin flexible camera is passed down to look directly at the gullet and stomach and take samples if needed. A barium swallow, where you drink a special liquid visible on X-ray, can show how food moves down and may reveal the tight lower valve and widened gullet seen in achalasia. The most specific test is oesophageal manometry, which measures the pressure and squeezing of the gullet muscles using a fine tube, and can confirm the abnormal pattern of achalasia. These tests together help distinguish achalasia from reflux narrowing, from cancer, and from other conditions, so the right treatment can be chosen.

Living with it and treatment

Achalasia cannot usually be cured, but several treatments can relax or widen the tight lower valve so food passes more easily and symptoms improve. Options include stretching the valve with a balloon during endoscopy, a keyhole operation to loosen the muscle, a newer endoscopic procedure to cut the tight muscle from the inside, and sometimes injections or medicines to relax it. The best choice depends on the person, and a specialist team will discuss the balance of benefits and risks. Practical measures help too: eating slowly, chewing well, drinking with meals, sitting upright and avoiding eating late at night can ease symptoms and reduce night-time regurgitation. Regular follow-up is important, and many people manage well for years. As always, any new alarm symptoms such as worsening swallowing or weight loss should prompt review.