Achalasia Cardia - Uncommon But Important Cause Of Swallowing Difficulty

The hallmark symptom of achalasia cardia is difficulty swallowing (dysphagia). Initially, patients may have trouble swallowing solid foods, but as the condition progresses, swallowing liquids also becomes difficult.

Common symptoms of achalasia cardia include:

• A sensation of food or liquids getting stuck in the chest after swallowing.
• Chest pain or discomfort while eating.
• Regurgitation of undigested food or saliva, especially when lying down.
• Coughing, choking, or liquid coming out through the nose during sleep due to regurgitation.
• Heartburn, inflammation, or ulceration of the food pipe (esophagus) caused by retained food.
• Gradual and unexplained weight loss.

Achalasia cardia usually develops slowly and worsens over time. Because the symptoms progress gradually, many patients adapt by eating more slowly or changing their posture, such as lifting the neck or throwing the shoulders back, to help food pass into the stomach. As a result, medical attention is often delayed until the symptoms become more severe.

Patients with long-standing achalasia cardia also have an increased risk of developing esophageal cancer. Early diagnosis, timely treatment, and regular follow-up are important to reduce complications and maintain long-term esophageal health.

The exact cause of achalasia cardia is not fully understood. However, researchers believe that several factors may contribute to the development of the condition, including:

• Autoimmune response: The body’s immune system may mistakenly attack the nerve cells of the food pipe (esophagus), leading to loss of normal esophageal muscle function.
• Viral infections: Certain viral infections, including some herpes viruses, are thought to trigger an abnormal immune response in susceptible individuals, although this has not been conclusively proven.
• Genetic predisposition: While achalasia cardia is not usually an inherited disorder, some people may have a genetic susceptibility that increases their risk of developing the disease.

Achalasia cardia is most likely caused by a combination of these factors rather than a single identifiable cause.

Yes, achalasia cardia can be treated without surgery in selected patients. Non-surgical treatment options include medications, endoscopic Botox injections, and pneumatic balloon dilatation. However, medications and Botox injections generally provide only temporary symptom relief and are not considered effective long-term treatments. Therefore, they are not routinely recommended for most patients.

The primary non-surgical treatment is pneumatic balloon dilatation.

Pneumatic balloon dilatation is an endoscopic procedure in which a specially designed balloon is positioned across the lower esophageal sphincter (LES) and inflated to stretch and split the tight sphincter muscle

Compared with surgery, pneumatic balloon dilatation is a less precise treatment and generally has lower long-term success rates. The LES may become tight again over time, and nearly one-third of patients require repeat balloon dilatation.

The procedure carries a 2–4% risk of esophageal perforation (a tear or hole in the food pipe), which usually requires emergency surgery. Since balloon dilatation does not include an anti-reflux procedure, patients also have a significantly higher risk of developing acid reflux after treatment.

Peroral Endoscopic Myotomy (POEM) is a minimally invasive endoscopic procedure used to treat achalasia cardia. Unlike laparoscopic surgery, POEM is performed entirely through the mouth without any external incisions.

During the procedure, the surgeon passes an endoscope through the mouth into the esophagus and creates a small incision in the inner lining of the food pipe. The tight lower esophageal sphincter (LES) muscle is then carefully divided under direct vision to allow food and liquids to pass into the stomach more easily. The incision is finally closed using endoscopic clips.

POEM provides relief from swallowing difficulty, with short-term results comparable to laparoscopic Heller’s myotomy. However, as it is a relatively newer procedure, long-term outcome data are still being evaluated.

Patients are usually admitted on the day of surgery or the night before the procedure. To prepare for surgery, a clear liquid diet is recommended for two days before POEM. This helps ensure that the food pipe is free of retained food, allowing the procedure to be performed safely.
Most patients are able to get out of bed and walk within a few hours after surgery. A liquid diet is usually started about two days after the procedure, followed by a soft diet over the next few days. These temporary dietary restrictions allow the incision in the inner lining of the esophagus to heal properly.

Most patients experience improvement in swallowing after POEM. However, because the procedure does not include an anti-reflux procedure (fundoplication), the risk of developing acid reflux is relatively high, occurring in approximately 40-60% of patients. Those who develop reflux may require long-term acid-suppressing medications.

Heller cardiomyotomy with partial fundoplication (Dor or Toupet), performed using robotic or laparoscopic minimally invasive surgery, is considered the gold standard surgical treatment for achalasia cardia. The procedure is performed through a few small incisions in the abdomen using a high-definition camera and specialized surgical instruments.

During a Heller cardiomyotomy, the surgeon carefully divides the tight lower esophageal sphincter (LES) muscle at the lower end of the food pipe (esophagus). This relieves the obstruction and allows food and liquids to pass more easily into the stomach. Since the procedure is performed under magnified vision, the muscle division is highly precise. If a small tear occurs in the inner lining of the esophagus during surgery, it is identified immediately and repaired during the same operation without affecting the overall outcome.

An intraoperative endoscopy is routinely performed to confirm that the LES has been adequately opened and to ensure there is no injury to the esophagus.

After the cardiomyotomy, the upper part of the stomach is partially wrapped around the lower end of the esophagus to create a partial fundoplication (Dor or Toupet). This anti-reflux procedure helps reduce the risk of acid reflux after surgery while maintaining the improved passage of food into the stomach.

No. Achalasia cardia is generally not an inherited genetic disorder and does not usually run in families. Most cases occur occasionally without a known family history.

No. Achalasia cardia does not cause heart disease or damage the heart. However, chest pain caused by achalasia can sometimes resemble cardiac chest pain, so proper evaluation is important to rule out heart-related conditions.

Yes, in rare cases, untreated achalasia cardia can become life-threatening. Severe food or liquid retention in the esophagus may regurgitate into the windpipe (trachea), leading to aspiration, choking, aspiration pneumonia, or serious lung infections.

Achalasia cardia can be distinguished from esophageal cancer using a combination of investigations, including upper GI endoscopy, CT scan, esophageal manometry, and biopsy when required. These tests help establish an accurate diagnosis and exclude malignancy.

If left untreated, achalasia cardia can lead to several complications, including:

• Esophagitis (inflammation or fungal infection of the food pipe)
• Bleeding from the esophagus
• Aspiration pneumonia
• Recurrent lung infections
• Increased risk of esophageal cancer over the long term