University of California San Francisco

Achalasia

Achalasia is a relatively rare disorder of the esophagus that makes it hard for foods and liquids to pass into the stomach.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue.

The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients ( vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body.

Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine.

Achalasia is caused by abnormal function of the nerves controlling the esophagus muscles and the valve or sphincter between the esophagus and stomach. In achalasia symptoms often develop slowly over time so that many patients often wait years before seeking medical treatment. 

Diagnosis

Since may other conditions may mimic achalasia, an accurate diagnosis is critical. Three tests are used to diagnose the condition

Barium Swallow 

A series of X-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.

In people who have achalasia, the X-rays reveal a dilated (enlarged ) esophagus and a narrowing of the lower end so that it resembles a bird's beak. With achalasia, the barium also stays in the esophagus longer than normal before passing into the stomach.

Esophagoscopy 

A procedure to look inside the esophagus to check to rule out esophageal cancer, which can also obstruct the passage of food and dilate the esophagus.

An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.   

Esophageal Manometry

A thin tube is inserted into the esophagus. The tube is connected to a pressure recorder, which measures muscle contractions of the esophagus when that patient swallow. In patients with achalasia,  no pressure waves appear in the lower half of the esophagus after a swallow.Manometry can often diagnose achalasia in its early stages.

Non-Surgical Treatment

Botulinum Toxin

Botox is injected directly into the esophageal sphincter using an endoscope. This treatment is usually reserved for patients at are poor risks for surgery because the injections, which weaken the sphincter muscle and allows food to pass into the stomach, must be repeated bi-monthly and make make later surgery more difficult.

Balloon Dilatation

A balloon is inserted into the esophageal sphincter using an endoscope and inflated to enlarge its opening. This outpatient procedure has a success rate of 50-75%.  Repeat treatment is required if the esophageal sphincter contracts and there a very small risk (2-6 %) of puncturing the esophagus during the procedure.

Surgical Treatment

The surgery to treat achalasia, called an esophagomyotomy, involves cutting the esophageal sphincter muscle. The operation's success rate is very high and usually permanent. A small number of patients may need addtional treatment.

Heller Myotomy

At UCSF, the surgery is usually performed as a laparoscopic (minimally invasive) procedure called a Heller myotomy. Several tiny incisions are made and small scope is inserted, through which miniature surgical instruments are passed. The scope if connected to a video camera which sends a magnified image  to a monitor, allowing the surgeon to envsion the anatomy and manipulate the instruments..

The advantages of the Heller Myotomy include:

  • Less post-operative pain
  • A 1-2 day hospital stay vs. up to a week with a conventioonal open procedure
  • Faster recovery from surgery
  • A more rapid return to work and normal activities

Nissen Fundoplication

Many patients develop gastroesophageal reflux disease (GERD) after a Heller myotomy. To avoid the this condition, where contents of the stomach reflux (back up) into the esophagus, a Nissen fundoplication is may also be performed with the Heller Myotomy.

This procedure, also performed  laparoscopically, involves wrapping the upper part of the stomach  around the lower esophegeal sphincter to strengthen it.