Achalasia is an oesophageal motor disorder characterised by a loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing.
The most common presenting symptoms are dysphagia to solids and liquids, regurgitation, and retrosternal pain. These can be slowly progressive over months or years.
The first investigation for any patient with dysphagia is usually endoscopy to exclude malignancy. Subsequent barium swallow studies and oesophageal manometry are often required to establish the diagnosis of achalasia.
Treatment is symptomatic, not curative, and is primarily aimed at relieving dysphagia; options include pharmacological, endoscopic, and surgical procedures.
Achalasia is an oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter relaxation in response to swallowing. This results from loss of inhibitory nitrinergic neurons in the oesophageal myenteric plexus.
History and exam
Key diagnostic factors
Other diagnostic factors
- posturing to aid swallowing
- retrosternal pressure/pain
- gradual weight loss
- slow eating
- coughing/choking while recumbent
- recurrent chest infections
- sensation of a lump in the throat (globus)
- herpes and measles viruses
- autoimmune disease
- HLA class II antigens
- consanguineous parents
- triple A (Allgrove) syndrome
1st investigations to order
- upper gastrointestinal endoscopy
- barium swallow
- high-resolution oesophageal manometry
Investigations to consider
- chest x-ray
- radionucleotide oesophageal emptying studies
- timed barium oesophagogram
- CT chest
patients awaiting definitive treatment
good surgical candidate
poor surgical candidate
Jin-Yong Kang, MD, PhD, FRCP, FRCPEd, FRACP
Honorary Consultant Gastroenterologist
St George's Hospital
JYK declares that he has no competing interests.
Kalliopi Alexandropoulou, MD, FRCP
Royal Surrey County Hospital
KA declares that he has no competing interests.
Dr Jin-Yong Kang would like to gratefully acknowledge Kalliopi Alexandropoulou, a previous contributor to this topic. KA declares that she has no competing interests.
Nigel Trudgill, MB ChB
Sandwell General Hospital
NT declares that he has no competing interests.
John de Caestecker, BChir
Consultant in General Medicine
Leicester General Hospital
JdC declares that he has no competing interests.
David Hackam, MD, PhD
Assistant Professor of Surgery
Children's Hospital of Pittsburgh
DH declares that he has no competing interests.
George Y. Wu, MD, PhD
Professor of Medicine
University of Connecticut Health Center
GYW is on the medical advisory boards of the following: Gilead Sciences, Bristol-Myers Squibb, AbbVie, and Intercept.
- Oesophageal carcinoma
- Reflux oesophagitis
- Connective tissue disorders (e.g., systemic sclerosis)
- American Society for Gastrointestinal Endoscopy guideline on informed consent for GI endoscopic procedures
- Guidelines for oesophageal manometry and oesophageal reflux monitoring
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