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.
- Upper gastrointestinal endoscopy is required to exclude cancer, peptic narrowing and eosinophilic oesophagitis, even when a barium study appears typical.
- High-resolution manometry is the defining physiological test and distinguishes type I, type II and type III achalasia using the current Chicago classification framework.
- A timed barium oesophagram quantifies emptying and oesophageal shape; a tapering bird-beak appearance supports the diagnosis but cannot exclude pseudoachalasia.
- Pneumatic dilation, laparoscopic Heller myotomy and peroral endoscopic myotomy are effective definitive options selected through an experienced multidisciplinary service.
- Type III spastic disease often favours a longer tailored myotomy, while type II generally has high response rates across established definitive treatments.
- Botulinum toxin injection has limited durability and is generally reserved for people who cannot undergo more durable intervention or as a carefully chosen bridge.
- Treatment reduces outflow resistance but does not restore normal peristalsis; recurrent dysphagia, reflux, aspiration and nutritional decline therefore require long-term review.
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.
The patient cannot swallow saliva or maintain hydration and may have a fluid-filled dilated oesophagus, creating immediate aspiration and metabolic risk.
Night cough, recurrent pneumonitis, wheeze, voice change or falling oxygen saturation can result from overspill of retained oesophageal contents.
Sudden persistent pain, tachycardia, fever, dyspnoea, pleural symptoms or subcutaneous gas after dilation or myotomy is an emergency until a leak is excluded.
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.
- Confirm the motor phenotype with high-resolution manometry and add a timed barium oesophagram to define emptying and anatomy.
- If age, rapidity, weight loss or resistance is discordant, pursue CT, repeat endoscopy or endoscopic ultrasonography before calling the disorder idiopathic.