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The main cause of Achalasia

Achalasia is a disorder in which the lower esophageal sphincter does not relax when food passes down the esophagus to the stomach. As a result, the esophagus becomes distended and filled with food, and food passes into the stomach very slowly. Achalasia is often associated with chest pain during eating, weight loss, and regurgitation of food. The lower esophagus gets distended as food & liquid are unable to pass into the stomach


-- Achalasia is a rare swallowing disorder that affects only 1 in every 100,000 people. Patients typically first note increasing difficulty swallowing. Most people are diagnosed between the ages of 25 and 60 years. It is usually a chronic condition that worsens over time and does not resolve.


-- People undergoing balloon dilatation are typically placed on a liquid diet 12 hours to two days in advance (a longer period is recommended in patients with a great deal of food in the esophagus). Using fluoroscopy, a physician advances a guide wire down the esophagus and positions it inside the LES. A deflated balloon is then advanced along this guide wire, positioned inside the LES, and inflated for about 60 seconds. The balloon is then deflated and withdrawn, and the person is monitored in a recovery area for five to six hours to detect any complications of the procedure. If there are no complications, people can usually resume eating after six hours. If a person's day-to-day symptoms do not improve, additional sessions can be performed.

Success rate -- A single balloon dilatation session continues to relieve symptoms of achalasia in about 60 percent of people one year after the procedure and in about 25 percent of people five years after the procedure. Higher success rates have been reported in some studies. The success rate at later time points has not been well studied, but some people have remained symptom-free for as long as 25 years.

Complications -- About 15 percent of people experience severe chest pain immediately after balloon dilatation, and some experience fever.

The most significant complication of balloon dilatation is creation of a hole (perforation) in the wall of the esophagus; this complication occurs in about 2 to 6 percent of people undergoing the procedure, and it is most likely to occur during the first dilatation session. Symptoms of persistent or worsening pain in the hours after the procedure may indicate a perforation. Some doctors routinely check x-ray and/or swallow tests immediately after the procedure to check for a perforation.

Most perforations are small, and some heal on their own with antibiotics and intravenous feeding. However, many doctors recommend surgery to repair these tears, regardless of their size. There is no way to predict perforation; however, it is sensible to choose a doctor who has a great deal of experience performing balloon dilatation procedures.

Other possible complications of balloon dilatation include bruising of the esophageal wall, damage to the esophageal lining, the development of small pockets (diverticula) in the esophagus or upper stomach, and the development of gastroesophageal reflux disease (GERD). Because the LES is the principal barrier which prevents the reflux of stomach contents into the esophagus, its disruption can lead to acid reflux. GERD occurs in about 2 percent of people after balloon dilatation, but is usually easily controlled with acid-reducing medications.

Surgery (myotomy) -- Myotomy can be used to directly cut the muscle fibers of the LES. The surgical technique used most often is called the Heller myotomy. In the past, surgery was performed through an open incision in the chest or abdomen, but it can now be performed through a tiny incision using a thin, lighted tube (a laparoscope or a thoracoscope). This new approach is less traumatic and shortens recovery time. Patients who undergo myotomy are given general anesthesia, and generally stay in the hospital for one to two nights.

  Success rate -- Surgery relieves symptoms in 70 to 90 percent of people. Symptom relief is sustained in about 85 percent of people 10 years after surgery and in about 65 percent of people 20 years after the surgery. Thus, surgery is a more permanent solution for achalasia than balloon dilatation or botulinum toxin injection (see below). However, surgery can also be associated with complications, is more invasive than balloon dilatation (and more costly).

  Complications -- Like balloon dilatation, there is a risk of reflux following myotomy, which, over time, can cause damage to the esophagus. Surgeons generally perform a fundoplication (wrapping a portion of the stomach around the esophagus to prevent regurgitation of stomach contents) at the time of surgery; however this does not always prevent reflux. The procedure requires general anesthesia, and patients are hospitalized for one to two days . Some post-operative pain is expected, which can be controlled with pain medications.

Botulinum toxin injection -- Botulinum toxin injection is the newest treatment for achalasia. The botulinum toxin temporarily paralyzes the nerve cells that signal the LES to contract thereby helping to relieve the obstruction. Botulinum toxin injection may also be used as a diagnostic test in people with suspected achalasia who have inconclusive test results.

  Procedure -- The injection procedure is performed during routine endoscopy, while patients are sedated. The botulinum toxin is injected directly into the LES.

Success rate

-- A single botulinum toxin injection session relieves symptoms in 65 to 90 percent of people in the short term (three months to approximately one year). Additional injections can relieve symptoms in patients whose symptoms return. Botulinum toxin injection is more likely to be effective in people over the age of 50 years and in people who have the vigorous form of achalasia.

When compared with balloon dilatation, botulinum toxin has a similar effectiveness for relieving symptoms in the first one to two years after the procedure; however, this prolonged effectiveness requires multiple botulinum toxin injections in 40 to 50 percent of people. The long-term safety and effectiveness of botulinum toxin injection is unknown.

  Complications -- About 25 percent of people have chest pain for a few hours after the procedure while about 5 percent develop heartburn. Damage of the esophageal wall and lining are rare. The short-term safety of botulinum toxin injection appears to be greater than the short-term safety of both balloon dilatation and surgery; this greater short-term safety may make botulinum toxin injection a better choice for people with other medical conditions.

LONG-TERM RISK OF ESOPHAGEAL CANCER -- People with achalasia have an increased risk of esophageal cancer, particularly if obstruction is not adequately relieved.

This discussion will be updated as needed every four months on our web site .