Non-surgical management of achalasia cardia– Medical management is usually not effective and reserved for only those people whose surgical treatment is contraindicated for some reason.
Muscle relaxants– Drugs that cause relaxation of lower esophageal sphincter such as isosorbide dinitrate, sublingual nifedipine or nitroglycerin may be used. But side effects of these medicines are common and patients may stop taking these medicines for side effects.
Botulinum toxin– injection of botulinum toxin through an endoscope in lower esophageal sphincter causes paralysis of its muscles. It relaxes lower esophageal sphincter spasm. This procedure takes about 1 hour.
Disadvantages of botulinum toxin injection–
1 The effect lasts for 3 to 6 months. So repeated injections are necessary.
2 Repeated injections can cause scarring of lower esophageal sphincter, it becomes difficult to perform a Heller myotomy if necessary, later on.
This therapy is reserved for those patients who cannot tolerate surgery for some reason.
Balloon dilatation of lower esophageal sphincter (pneumatic dilatation)- with the help of an endoscope a specially designed balloon is inserted through lower esophageal sphincter and then inflated. As a result, the lower esophageal sphincter muscles are stretched and torn. This relaxes the lower esophageal sphincter and food, or drink can easily pass through the lower esophageal sphincter.
Usually, it can be done under sedation. The procedure takes about 15 minutes and hospital stay is usually one day.
Disadvantages of balloon dilatation–
1 The Effect is not long lasting. Repeated procedures may be necessary several times to maintain its effect.
2 Pneumatic dilatations may not be effective at the young age group as the chance of recovery of torn fibers at the young age group is more.
3 There is a small risk of perforation of the esophagus.
4 Pneumatic dilatations also cause scarring of the lower esophageal sphincter, and it becomes difficult to perform a Heller myotomy if necessary, later on.
Heller myotomy with fundoplication
Surgical management of achalasia cardia–
Heller myotomy– effective in 90% achalasia patients. In this procedure the muscles and submucosal layer of the lower part of esophagus, lower esophageal sphincter and upper part of stomach are cut from outside and the inner mucosal layer remains intact. Incision starts 8 cm above lower esophageal sphincter and extends 2 cm below it.
Lower esophageal sphincter becomes relaxed, and food and liquid can pass easily from the esophagus to the stomach.
It can be done through laparoscopic surgery (Laparoscopic Heller Myotomy) or open abdominal surgery.
Laparoscopic Heller Myotomy (keyhole surgery)–
In laparoscopic surgery 4 to 5 small incisions are made in the abdomen through which light, camera and tools for performing the operation is passed. With the help of a screen the surgeon can see the field of operation and perform the operation. The procedure usually takes 2 hours.
Advantages of laparoscopic surgery –
1 Less abdominal scar
2 Less pain and blood loss. .
3 Short recovery time and shorter hospital stay. The patient can be released 36 to 48 hours after surgery.
In open surgery a large incision is made in the abdomen so that stomach and esophagus can be accessed directly.
Disadvantage of Heller myotomy –
As the muscles of the lower esophageal sphincter are cut there is constant loosening of lower esophageal sphincter. Gastroesophageal reflux disease (GERD) may develop as a side effect of this procedure (In GERD stomach contents flow back up through the esophagus).
Therefore, an additional procedure called fundoplication may be done to avoid GERD.
In this procedure the upper portion of the stomach(fundus) is wrapped around the lower portion of the esophagus and sewed in place. As a result, the strength of lower esophageal sphincter increases and reflux of stomach content back into the esophagus is prevented.
By preventing GERD chances of Barrett’s esophagus and esophageal cancer can also be reduced.
[Read more about Barrett’s esophagus]
[Read more about fundoplication.]
Fundoplication can be done by open abdominal surgery or laparoscopic surgery.
Side effects of fundoplication–
1 Abdominal bloating,
2 Dysphagia (that may improve with time).
Robotic laparoscopic myotomy for achalasia cardia– Robotic laparoscopic myotomy at 5 o’clock position preserves the gastroesophageal valve. Because the gastroesophageal valve extends from 4 o’clock to 7 o’clock position. This procedure doesn’t cause gastroesophageal reflux disease and obviates the need for a fundoplication.
Peroral Endoscopic myotomy (POEM)– in this procedure an endoscope (a flexible tube with light and camera) is inserted through the mouth. With the help of a special knife at the tip of the endoscope an incision is made in the inner lining of the esophagus (mucosa) and a tunnel is made in the esophagus (between mucosal and submucosal layer) to reach the lower esophageal sphincter.
The inner muscle layer of lower esophagus, lower esophageal sphincter and upper part of stomach is cut. This relieves the spasm of the lower esophageal sphincter and the food or liquid can easily pass through it. The incision of the inner lining of the esophagus is closed and the endoscope is removed. It is done under general anesthesia and takes about 1¹/2 hours.
Advantages of POEM–
It is becoming increasingly popular.
1 This is an endoscopic procedure where no scar is visible.
2 Less sedation is necessary.
3 Operative time and staying at hospital (1 to 2 days) is short.
4 The patient recovers quickly.
5 Negligible blood loss.
6 The chance of infection is less.
7 May be done when other operative procedures were not successful.
Monitoring after surgery-
Regular check of esophagus with barium swallow x-ray or endoscopy to detect any stricture formation or premalignant condition such as Barrett’s esophagus.
Lifestyle changes in achalasia cardia before as well as after surgery
1 Achalasia cardia patients should eat slowly, food to be chewed well. Drink plenty of water during meals.
2 Eat a meal at least 3 hours before lying down. Avoid eating meals late at night.
3 Raise the head end of the bed or raise the upper portion of the body while sleeping with a wedge pillow. It will facilitate entering food from the esophagus to the stomach by gravity.
4 Drugs such as H2 blocker or proton pump inhibitors can be used to reduce gastric acid secretion to prevent reflux esophagitis.
5 Foods that cause more acid secretion or increased reflux of acid secretion such as citrus fruits, alcohol, caffeine, ketchup should be avoided.
Counseling and Emotional Support
Living with a chronic condition like Achalasia Cardia can be physically and emotionally draining. Anxiety about eating in public, fear of choking, or dealing with repeated medical procedures can take a toll on mental health.
1. Psychological Support
Seeking therapy or counseling helps manage stress and emotional exhaustion. A licensed therapist can guide coping mechanisms for dealing with long-term illness.
2. Support Groups
Joining an Achalasia support group, whether online or local, provides comfort through shared experiences. It’s reassuring to talk with others who truly understand your challenges.
3. Patient Education
Understanding the condition empowers patients to take charge of their treatment. Ask your healthcare provider for educational materials or attend patient workshops.
4. Family Involvement
Family and friends play a vital role. Educate them about your condition so they can support you during flare-ups or difficult meal times.
Emotional resilience is as crucial as medical management. Feeling supported can make the treatment journey less daunting.
Prognosis and Long-Term Outlook
With appropriate treatment and care, most people with achalasia lead normal, fulfilling lives. Although the disorder cannot be fully reversed, symptom control is achievable in nearly all cases.
1. Long-Term Management
Regular follow-up is essential, as achalasia may recur even after successful treatment. Repeat procedures or lifestyle adjustments are often sufficient to keep symptoms under control.
2. Monitoring for Cancer
Because achalasia slightly increases the risk of esophageal cancer, doctors may recommend periodic endoscopies to detect changes early.
3. Quality of Life
Patients who undergo surgical or endoscopic treatments typically experience significant improvement in swallowing, weight maintenance, and overall well-being.
Conclusion
Achalasia Cardia is a rare yet manageable condition affecting the esophagus. Understanding its causes, symptoms, and treatment options empowers patients to seek timely medical help and lead a better quality of life. Modern therapies like Heller Myotomy and POEM, combined with lifestyle adjustments and emotional support, offer effective relief from this chronic disorder.
If you or someone you know experiences persistent difficulty swallowing, don’t ignore it. Early diagnosis and treatment are key to preventing complications and ensuring long-term health.
Frequently Asked Questions (FAQs)
1. Is achalasia a curable disease?
No, achalasia isn’t completely curable, but its symptoms can be effectively managed through procedures like myotomy, balloon dilation, or Botox injections.
2. How long does treatment relief last?
Surgical options like Heller Myotomy or POEM offer long-term relief—often lasting 10 years or more—while balloon dilation may need periodic repetition.
3. Can diet alone manage achalasia?
Diet helps relieve discomfort but cannot correct the underlying muscle dysfunction. Medical or surgical treatment is usually required.
4. Does achalasia increase cancer risk?
Yes, long-term achalasia slightly raises the risk of esophageal cancer, emphasizing the need for regular endoscopic check-ups.
5. Which doctor treats achalasia?
A gastroenterologist or esophageal surgeon specializes in diagnosing and managing achalasia.
External Authoritative Sources:
- Mayo Clinic – Achalasia Overview
- Cleveland Clinic – Achalasia Causes and Treatments
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Achalasia cardia: Symptoms, Causes, Prevention and Diagnosis
