Achalasia
Achalasia is a rare but serious condition that affects the esophagus, causing difficulty in swallowing and other digestive problems. If you're struggling with swallowing issues or other related symptoms, understanding achalasia, how it is managed, and the treatment options available can help you make informed decisions about your health.
What is Achalasia?
Achalasia is a disorder of the esophagus where the muscles in the lower part of the esophagus (the lower esophageal sphincter or LES) fail to relax properly. The muscles in the esophagus itself have trouble contracting to push food down to the stomach due to chronic resistance from the LES. This leads to dysphagia (difficulty swallowing), regurgitation, and other gastrointestinal issues as well as weight loss and malnutrition.
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The exact cause of achalasia is not always clear, but it is believed to result from damage to the nerve cells in the esophagus, which can be due to autoimmune factors or other unknown causes. Without proper motility (muscle contractions), the food and liquids you swallow can't easily pass into the stomach, leading to a build-up of food in the esophagus and discomfort.
What are the Symptoms of Achalasia?
The symptoms of achalasia are often progressive, starting with mild discomfort and gradually worsening over time. Common symptoms include:
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Difficulty swallowing (dysphagia): Both solid foods and liquids become difficult to swallow as the condition progresses.
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Regurgitation of food: Food may come back up into the throat or mouth, especially after eating.
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Chest pain or discomfort: Some people experience chest pain, which may mimic the pain associated with heart conditions.
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Weight loss: Difficulty eating and the inability to swallow properly may lead to unintentional weight loss.
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Coughing or choking while eating: The inability to fully swallow food can result in coughing or choking episodes.
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Heartburn: Some patients may also experience symptoms resembling acid reflux or GERD, though these symptoms are caused by a different mechanism than traditional acid reflux.
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How is Achalasia Managed?
The treatment of achalasia focuses on relieving symptoms, improving the ability to swallow, and preventing complications like food accumulation or aspiration. Management can vary depending on the severity of the condition, but the general goals include improving esophageal motility and reducing the pressure in the lower esophagus. Common simple management approaches are below. Please note, the management of achalasia very much requires endoscopic or surgical procedures as medications and lifestyle modifications are rarely effective in the long term.
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Lifestyle and Dietary Modifications
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Eating smaller, more frequent meals: Smaller portions can help with swallowing difficulties.
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Drinking plenty of liquids: Helps to clear food from the esophagus more easily.
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Eating softer foods: Soft, moist foods can be easier to swallow than dry, tough foods
Medications
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Medications that relax the lower esophageal sphincter, such as nitrates or calcium channel blockers, may be used in some cases. However, they are generally less effective for long-term management compared to other treatment options.
Botox (Botulinum toxin) Injections
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Botulinum toxin (Botox) is sometimes injected into the lower esophageal sphincter to temporarily paralyze the muscle and relieve symptoms. This is typically considered for patients who are not candidates for surgery or other more invasive treatments. However, the effects are often temporary, and repeated injections may be necessary.
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Pneumatic Dilation
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Pneumatic dilation involves using a balloon to stretch the lower esophageal sphincter. This procedure can provide relief in some patients but may require repeat procedures over time.
Endoscopic vs. Surgical Procedures for Achalasia
When conservative treatments like medications or botox injections are insufficient, more invasive treatments may be needed. The two primary options are endoscopic procedures and surgical interventions.
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Endoscopic Procedure:
POEM (Peroral Endoscopic Myotomy)
POEM is a non-invasive procedure that uses an endoscope (a long, flexible tube with a camera) to make an incision in the mucosal lining of the esophagus and cut the muscle fibers of the lower esophageal sphincter. This reduces the pressure and allows food to pass into the stomach more easily.
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Advantages of POEM include:
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Minimal recovery time: POEM is less invasive than traditional surgery, with faster recovery and fewer complications.
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Less risk of esophageal perforation: Compared to other treatments, the risk of perforation during POEM is relatively low.
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Effective for both early and advanced cases of achalasia
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However, POEM procedure can lead to more post-operative acid reflux compared to the Heller Myotomy due to the inability to perform an acid reducing component to the procedure. Additionally, POEM is not suitable for everyone, particularly patients with large, advanced cases or those who have significant scarring in the esophagus.
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Surgical Procedure: Heller Myotomy
Heller myotomy is a traditional surgical procedure in which the surgeon makes an incision and cuts the muscles of the lower esophageal sphincter. This allows for better food passage into the stomach. Next, a partial fundoplication (a procedure where the top of the stomach is wrapped around the esophagus) is performed to prevent gastroesophageal reflux (GERD) after the surgery. This is performed laparoscopic or robotic through tiny incisions.
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Advantages of Heller Myotomy include:
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Long-established: It has been a standard treatment for achalasia for many years and is well-researched.
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More durable results: It has been shown to provide long-lasting relief in most patients, particularly for those with more advanced disease.
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Effective for large cases of achalasia.
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However, Heller myotomy requires one night hospital stay and slightly more pain due to the surgical nature of the procedure.
Finding the Right Treatment for Achalasia
If you're living with achalasia, there are treatment options available to help you manage symptoms and improve your quality of life. Both POEM and Heller myotomy offer effective solutions, but the right choice depends on the severity of your condition, your overall health, and your preferences. Working closely with Dr. Siegal will help you understand your options and determine the best treatment for your individual needs.