General and Gastrointestinal Surgery

Surgical Treatment of Achalasia

Symptoms of achalasia suggest that a narrowing is present at the lower part of the esophagus. These symptoms include:

  • difficulty swallowing
  • painful swallowing
  • frequent regurgitation of undigested food and saliva
  • bad breath
  • back pain
  • shoulder pain
  • chest pain

Often, people with achalasia must sleep sitting up. They often note that their symptoms worsen with stress or ingestion of cold liquids. Although the abnormal area in the esophagus is located near the lowest portion of the breast bone, most people experience symptoms at the mid- to upper level of their chest and back.

Diagnosis Q&A

Patients who have difficulty swallowing will usually be asked to obtain an upper GI series. An upper GI series is a series of x-rays taken as the patient swallows barium, a chalky, pink liquid. The radiologist will observe any abnormalities in the esophagus while the patient swallows. Achalasia is often suspected if a long, tapered narrowing of the esophagus is observed. Alternatively, the narrowing may indicate an esophageal stricture.

How is achalasia diagnosed?

The diagnosis of achalasia is made by an esophageal motility test. The esophageal motility, or manometry, test measures the motion or contraction of the esophagus and the pressures it generates during contraction. This allows the measurement of the pressure and length of the LES, and how well the lower esophagus relaxes in response to swallowing. It also allows detection of high amplitude contractions, or spasms, and reflux or gastro-esophageal reflux disease. Achalasia is confirmed when the pressure of the LES is abnormally high and the LES does not relax with swallowing. A stricture is usually associated with a normal or low LES and relaxation with swallowing.

How is an esophageal motility test performed?

The test, which lasts about one hour, involves passing a small tube into the esophagus. The pressures in your esophagus are measured at 5 sites, called channels. Patients are asked to swallow and then swallow water to determine not only the pressure present but also the coordination of the contractions in the esophagus.

What is an EGD?

An EGD is a esophagogastroduodenoscopy, also known as an upper endoscopy. A tube about ½ inches in diameter is placed through your mouth into your esophagus, stomach and then duodenum. The tube is attached to a video monitor allowing the doctor to look at those three organs for abnormalities such as reddening, ulcers and tumors. It is a very common procedure that lasts only a few minutes, and is usually performed with some sort of sedation.

What is an esophageal stricture?

An esophageal stricture is a narrowing, usually at the very end of the esophagus, that is the result of chronic scarring from acid reflux into the esophagus or from a tumor. It results in painful swallowing and weight loss. It is usually first diagnosed by upper GI x-ray series. This stricture is distinguished from a narrowing caused by cancer or a tumor through  an upper endoscopy and biopsy. It is distinguished from a narrowing caused by achalasia by an x-ray, as the lower esophageal sphincter relaxes in a stricture but it does not in achalasia. 

Strictures are treated by dilation. Tubes of increasing diameters, or an inflatable balloon, are passed down the throat and through the esophagus into the stomach until the desired size of the esophagus is reached. This is almost always successful in restoring swallowing but it may offer only temporary relief. The stricture may recur, especially if the reflux is not eliminated. The latter is done with medications or surgery.