Achalasia is a disorder of the esophagus in which the lower esophageal sphincter fails to relax and the esophagus loses its normal muscle waves. Food and liquid stay in the esophagus, causing slowly worsening trouble swallowing.
Key symptoms
- Trouble swallowing both solids and liquids
- Regurgitation of undigested food, often at night
- Chest pain or heartburn
- Weight loss
- Night cough from aspiration
What you find on exam
- Often normal
- Weight loss and signs of malnutrition
- Lung crackles if aspiration
- Lymph nodes or a mass that suggest cancer
Tests
- Upper endoscopy first to rule out cancer (pseudoachalasia)
- Barium swallow: dilated esophagus with bird's beak narrowing
- High-resolution esophageal manometry confirms the diagnosis and subtype
- Timed barium swallow to track response to treatment
Treatment basics
- Pneumatic balloon dilation
- Laparoscopic Heller myotomy with partial fundoplication
- Peroral endoscopic myotomy (POEM)
- Botulinum toxin injection for patients who cannot have surgery
- Nifedipine or nitrates before meals as a short-term bridge
Red flags
- Rapid weight loss in an older patient (suspect cancer)
- Recurrent pneumonia or aspiration
- Unable to swallow saliva or food stuck in the esophagus
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.