Synopsis
Recognise achalasia, confirm impaired oesophagogastric junction relaxation, exclude pseudoachalasia and select safe specialist treatment with durable follow-up.
- Achalasia is a primary motor disorder in which lower oesophageal sphincter relaxation fails and organised peristalsis is lost because inhibitory enteric neurones are impaired.
- Dysphagia usually affects liquids as well as solids from early in the history, whereas purely progressive solid-food dysphagia first suggests a mechanical obstruction.
- Regurgitation of bland retained food, nocturnal cough, recurrent chest infection, chest discomfort and unintentional weight loss are common but not individually diagnostic.
Key red flags
A short rapidly worsening history, substantial weight loss, anaemia, older age at onset or unusual endoscopic resistance raises concern for junctional or proximal gastric malignancy.
Investigation priorities
Exclude a structural cause and inspect for retained contents or mucosal injury.
Management branches
Liquids-and-solids dysphagia or retained-content regurgitation suggests an oesophageal motor disorder.
- Assess obstruction, aspiration, hydration, nutritional state and cancer alarm features; admit urgently when saliva cannot be handled or respiratory compromise is developing.
- Perform expert endoscopy with clearance of retained material as safely feasible, targeted biopsies of abnormalities and deliberate inspection of the cardia and proximal stomach.
Key medicines
Endoscopic botulinum toxinAn advanced endoscopist injects the lower oesophageal sphincter using the service's current preparation, total dose and quadrant technique; there is no safe universal bedside regimen for unsupervised prescribing.
Proton pump inhibitor after sphincter disruptionUse a licensed full-dose PPI selected from the current BNF when post-myotomy reflux is expected, demonstrated or symptomatic, then adjust to objective findings and the lowest effective maintenance plan.