Achalasia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 22 Sep 2025

Last updated: 01 Oct 2025

Achalasia is an esophageal motor disorder characterized by a loss of esophageal peristalsis and failure of the lower esophageal 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 esophageal manometry are often required to establish the diagnosis of achalasia.

Treatment is symptomatic, not curative, and is primarily aimed at relieving dysphagia; options include pharmacologic, endoscopic, and surgical procedures.

Definition

Achalasia is an esophageal motor disorder of unknown etiology, characterized by esophageal aperistalsis and insufficient lower esophageal sphincter relaxation in response to swallowing. This results from loss of inhibitory nitrergic neurons in the esophageal myenteric plexus.

History and exam

Key diagnostic factors

dysphagia

Full details

Other diagnostic factors

posturing to aid swallowing
retrosternal pressure/pain
regurgitation
gradual weight loss
heartburn
slow eating
coughing/choking while recumbent
recurrent chest infections
sensation of a lump in the throat (globus)
hiccups

Full details

Risk factors

herpes and measles viruses
autoimmune disease
HLA class II antigens
consanguineous parents
triple A (Allgrove) syndrome

Full details

Diagnostic tests

1st tests to order

upper gastrointestinal endoscopy
barium swallow
high-resolution esophageal manometry

Full details

Tests to consider

chest x-ray
radionucleotide esophageal emptying studies
timed barium esophagogram
CT chest
impedance planimetry

Full details

Treatment algorithm

INITIAL

patients awaiting definitive treatment

ACUTE

good surgical candidate

poor surgical candidate

Contributors

Authors

Jamal Omar Hayat, MBBS, BSc, MRCP, MD (Res)

Consultant Gastroenterologist and Honorary Senior Lecturer

Department of Gastroenterology

St George's University Hospitals NHS Trust

London

Disclosures

JOH declares that he has no competing interests.

Kalliopi Alexandropoulou, MD, FRCP

Consultant Gastroenterologist

Royal Surrey County Hospital

Guildford

Surrey

Disclosures

KA declares that sshe has no competing interests.

Acknowledgements

Dr Jamal Omar Hayat and Dr Kalliopi Alexandropoulou wish to gratefully acknowledge Dr Jin-Yong Kang, the previous contributor to this topic.

Disclosures

JYK declares that he has no competing interests.

Peer reviewers

Nigel Trudgill, MB ChB

Consultant Gastroenterologist

Sandwell General Hospital

West Bromwich

Disclosures

NT declares that he has no competing interests.

John de Caestecker, BChir

Consultant in General Medicine

Leicester General Hospital

Leicester

Disclosures

JdC declares that he has no competing interests.

David Hackam, MD, PhD

Assistant Professor of Surgery

Children's Hospital of Pittsburgh

Pittsburgh

Disclosures

DH declares that he has no competing interests.

George Y. Wu, MD, PhD

Professor of Medicine

University of Connecticut Health Center

Farmington

Disclosures

GYW is on the medical advisory boards of the following: Gilead Sciences, Bristol-Myers Squibb, AbbVie, and Intercept.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Zaninotto G, Bennett C, Boeckxstaens G, et al. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018 Sep 1;31(9).Full text Abstract

Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol. 2020 Sep;115(9):1393-411.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Esophageal carcinoma
- Reflux esophagitis
- Connective tissue disorders (e.g., systemic sclerosis)
More Differentials
Guidelines
- Adverse events associated with EGD and EGD-related techniques
- Diagnosis and management of achalasia
More Guidelines
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Achalasia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

patients awaiting definitive treatment

good surgical candidate

poor surgical candidate

Contributors

Authors

Jamal Omar Hayat, MBBS, BSc, MRCP, MD (Res)

Disclosures

Kalliopi Alexandropoulou, MD, FRCP

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Nigel Trudgill, MB ChB

Disclosures

John de Caestecker, BChir

Disclosures

David Hackam, MD, PhD

Disclosures

George Y. Wu, MD, PhD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice