Having trouble swallowing? Could it be Achalasia? Let's talk about this!

Have you ever felt like your food or drink is stuck in your esophagus? Or have you experienced chest pain and food coming back up into your throat? These can be very annoying in your daily life. Today we are going to talk about a condition that can cause similar symptoms, but is not very common. That is a condition called `Achalasia` (aka `Cardiospasm`).

What is `Achalasia`? Let's understand it simply!

Simply put, `Achalasia` is a rare condition in which our esophagus, the tube that carries food from our mouth to our stomach, does not work properly. Did you know that our esophagus is not just a tube? It is a tube made of muscles. When we swallow something, these muscles contract (like a wave) and push the food down. We call this process `(Peristalsis)`.

Now imagine that at the very bottom of the esophagus, where food enters the stomach, there is a ring of muscle that looks like a gate. This is called the ``Lower Esophageal Sphincter`` or ``LES.`` Normally, when food gets close to this ``LES``, it opens (relaxes) and allows the food to pass into the stomach. Then it closes again, stopping the contents of the stomach from coming back up into the esophagus.

However, in someone with `Achalasia`, this process is disrupted.

1. The peristalsis-like movement in the digestive tract is not happening properly, or is very weak.

2. That door called `LES` doesn't open properly when the food arrives. It's stuck.

So what happens? The things you eat and drink get stuck in your esophagus, not going into your stomach. This causes difficulty swallowing, chest pain, and food coming back up into your throat. Over time, the body can lose weight and develop nutritional deficiencies because it doesn't get enough food.

`Achalasia` is not a very common disease. In a country like America, it affects about one in a hundred thousand people. It usually affects older people, between the ages of 25 and 60. However, sometimes young children can also develop this condition.

What are the symptoms of `Achalasia`? How is it diagnosed?

The symptoms of `Achalasia` do not appear suddenly. Most of the time, they develop slowly. You may not notice the difference for months or years. The main symptoms that can be seen are:

• Difficulty swallowing (Dysphagia): This is the main symptom. It may be difficult to swallow solid foods first, and then liquids.
• Regurgitation: This is not the same as vomiting, but undigested food comes back up into the throat. This can happen especially at night while sleeping.
• Chest pain: Sudden, sometimes severe, pain in the chest can be so severe that it can be thought of as a heart attack.
• Difficulty urinating.
• Heartburn: But this may be different from the inflammation of normal gastritis.
• Hiccups.
• Unexplained weight loss: Weight loss occurs over time because food is not being absorbed properly by the body.

Remember, these symptoms get worse over time, so it's important to seek medical advice if you notice even the slightest change.

What causes `Achalasia`?

In fact, experts still don't know the exact cause of achalasia. However, there is one main theory. That is, it is an autoimmune disease, meaning that our own immune system attacks our own body's own cells. According to this theory, something like this happens:

1. Our immune system is activated by something like a virus.

2. However, by mistake, this immune system begins to attack the nerve cells that control the muscle activity in our esophagus.

3. These nerve cells are gradually being destroyed.

4. Then the movement (peristalsis) that pushes food down the esophagus and the opening of the LES do not happen properly.

This is the currently accepted view, but further research is being conducted.

What are the possible complications of `Achalasia`?

With achalasia, food is stuck in the esophagus, which can cause it to come back up into the throat and sometimes into the windpipe. If this happens, it can cause various complications. For example:

• Aspiration pneumonia: A condition of pneumonia caused by food entering the lungs.
• Bronchiectasis: Damage to the airways in the lungs.
• Lung infections.
• Increased risk of esophageal cancer: This risk increases due to food getting stuck in the esophagus for a long time and inflammation.
• Malnutrition: This is due to a lack of food in the body.

That is why it is important to diagnose and treat Achalasia quickly.

How do doctors diagnose `Achalasia`?

If you have the symptoms mentioned above, when you see a doctor, they will ask you about your symptoms, how long they have been present, etc. They will then perform a physical examination. Three main tests are used to confirm the diagnosis of achalasia:

1. Esophagram (Barium Swallow): In this test, you are given a liquid called barium to drink. An X-ray is then taken to see how food moves down the esophagus. If you have achalasia, the esophagus is swollen and the LES does not open properly.

2. Esophageal manometry test: In this, a thin tube is inserted through the nose into the esophagus and the way the muscles of the esophagus contract and the pressure of the `LES` are measured. In `Achalasia`, the pressure of the `LES` is high, and the movement of the esophagus (peristalsis) is absent. This is the best test to diagnose `Achalasia`.

3. Upper endoscopy: A thin, flexible tube with a camera attached is inserted through the mouth into the esophagus and stomach to look inside. This can also help to check for other problems in the esophagus (such as cancer). Sometimes a biopsy, which is a small piece of tissue, may be taken for examination.

What are the treatments for `Achalasia`?

The main goal of treatment for achalasia is to relax the LES muscle at the bottom of the esophagus, allowing food to pass into the stomach. These treatments cannot completely cure achalasia , but they can control symptoms and make life easier. Your doctor will consider your symptoms, age, and your preferences to determine the best treatment option.

Nonsurgical treatment

• Balloon dilation: In this, a special balloon is passed through the esophagus, similar to an endoscopy, to the area where the LES is located, and the balloon is inflated. Then, the tight muscle ring stretches and relaxes a little. This creates a path for food to pass through. This is done under light anesthesia. This treatment may need to be repeated several times.
• Medication: There are some medications that can relax the LES.
• Botox® (botulinum toxin) injection: Botox is injected into the LES through an endoscopy. This temporarily paralyzes and relaxes the muscle. However, the effect only lasts for a few months and must be repeated.
• Tablets such as `Nifedipine` (`Procardia XL®`, `Adalat CC®`) or `Isosorbide` (`Imdur®`, `Monoket®`). These should be taken before meals and relax the `LES`. However, these do not work for everyone and can have side effects.

Surgical treatment

There are several surgical procedures that can be performed to relax the LES. These are often performed without a large incision, through small incisions (`Laparoscopic` / `Minimally invasive`).

• Laparoscopic Heller myotomy: This is the most common surgery. In this, an instrument, similar to an endoscope, is inserted through small incisions in the abdomen and the muscle fibers of the LES are cut (myotomy means to cut the muscle). This relaxes the LES. Often, a procedure called a fundoplication is also done, which involves wrapping the upper part of the stomach around the esophagus to reduce the reflux of stomach acid into the esophagus (GERD).
• Peroral endoscopic myotomy (POEM): This is a new procedure. In this, an endoscope is inserted through the mouth, goes under the lining of the esophagus, and cuts the muscle of the LES. This does not require an external incision.

Very rarely, if symptoms are very severe and other treatments have not worked, your doctor may recommend surgery to remove the entire esophagus (an esophagectomy).

Complications of treatment

Laparoscopic Heller myotomy and POEM surgeries are very successful. However, some complications can occur:

• Reappearance of `Achalasia` symptoms.
• GERD (Gastroesophageal reflux disease) (especially if fundoplication is not performed after Heller myotomy).
• Very rarely, perforation of the esophagus during surgery.

What can you expect if you have `Achalasia`?

Symptoms of achalasia can sometimes recur even after treatment. Therefore, long-term medical monitoring (`follow-up`) is very important. Your doctor will check you regularly:

• Tests are performed to ensure that food and liquids are passing through the esophagus into the stomach properly.
• Check for signs of GERD.
• Check for early signs of esophageal cancer (this risk is slightly higher with achalasia).

If left untreated, achalasia can lead to nutritional deficiencies and can be life-threatening. However, with proper treatment, a person without achalasia can live a normal life span.

How do I take care of myself?

When living with a condition called `Achalasia`, there are several things you can do to help pass food and drink through the esophagus more easily and manage symptoms:

• Cut food into small pieces and chew it well.
• Drink plenty of water while eating. This will moisten the food and help it go down more easily.
• Eat while sitting up straight. This will help gravity move the food down.
• Avoid eating solid foods three to four hours before bed. This will give your stomach time to digest the food before you fall asleep.
• Keep an extra pillow under your head when you sleep. Keeping your head elevated will help reduce the chance of food from the esophagus going into the windpipe.

What foods should be avoided if you have `Achalasia`?

Because achalasia makes it difficult for food to pass through the esophagus, certain foods can worsen symptoms. Be especially careful with foods like these:

• Foods that can block the esophagus: For example, unpeeled apples, grapes, raw vegetables, fibrous or dried meats.
• Foods that can thicken and accumulate in the esophagus: For example, bread (especially white bread), white rice, potatoes, chips, and pasta.
• Foods that can irritate the throat: For example, spicy foods, carbonated drinks, and alcoholic beverages.

These foods don't affect everyone the same. You have to figure out for yourself through experience what foods are difficult for you.

When should I see a doctor?

If you notice any new changes in your body, especially new symptoms of Achalasia, such as difficulty swallowing , see a doctor immediately.

Achalasia is a rare condition where symptoms develop gradually over time. Symptoms can range from heartburn to hiccups to difficulty swallowing. So you may not immediately think that all of these symptoms are related to one disease.

However, it is important to talk to a doctor about any symptoms that persist, even if they seem unrelated. There are several treatments for achalasia. Your doctor can explain each treatment to you and help you choose the one that is best for you. Don't worry, if you get diagnosed and treated early, you can manage the condition well.

Summary (Take-Home Message)

`Achalasia` is a condition in which the muscles in the lower part of the esophagus do not function properly, preventing food from passing into the stomach. Symptoms include difficulty swallowing, chest pain, and food getting into the throat. There are special tests to diagnose this. Treatments include balloon dilation of the muscles, medications, and surgery. Although there is no complete cure, symptoms can be well controlled and you can live a normal life. If you have these symptoms, do not hesitate to seek medical advice. Your health is in your hands!

` Achalasia, Cardiospasm, Difficulty swallowing, Esophagus, LES, Dysphagia, Esophageal Manometry