Achalasia - Treatment

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How is achalasia treated?

Treatments for achalasia include oral medications, stretching of the lower esophageal sphincter (dilation), surgery to cut the sphincter (esophagomyotomy), and the injection of botulinum toxin (Botox) into the sphincter. All four treatments reduce the pressure within the lower esophageal sphincter to allow easier passage of food from the esophagus into the stomach.

Oral medications

Oral medications that help to relax the lower esophageal sphincter include groups of drugs called nitrates, for example, isosorbide dinitrate (Isordil) and calcium channel blockers, for example, nifedipine (Procardia) and verapamil (Calan). Although some patients with achalasia, particularly early in the disease, have improvement of symptoms with medications, most do not. By themselves, oral medications are likely to provide only short-term and not long-term relief of the symptoms of achalasia, and many patients experience side-effects from the medications.

Dilation

The lower esophageal sphincter also may be treated directly by forceful dilation. Dilation of the lower esophageal sphincter is done by having the patient swallow a tube with a balloon at the end. The balloon is placed across the lower sphincter with the help of X-rays, and the balloon is blown up suddenly. The goal is to stretch--actually to tear--the sphincter. The success of forceful dilation has been reported to be between 60% and 95%. Patients in whom dilation is not successful can undergo further dilations, but the rate of success decreases with each additional dilation. If dilation is not successful, the sphincter may still be treated surgically. The main complication of forceful dilation is rupture of the esophagus, which occurs 5% of the time. Half of the ruptures heal without surgery, though patients with rupture who do not require surgery should be followed closely and treated with antibiotics. The other half of ruptures require surgery. (Although surgery carries additional risk for the patient, surgery can repair the rupture as well as permanently treat the achalasia with esophagomyotomy.) Death following forceful dilation is rare. Dilation is a quick and inexpensive procedure compared with surgery, and requires only a short hospital stay.

Esophagomyotomy

The sphincter also can be cut surgically, a procedure called esophagomyotomy. The surgery can be done using an abdominal incision or laparoscopically through small punctures in the abdomen. In general, the laparoscopic approach is used with uncomplicated achalasia. Alternatively, the surgery can be done with a large incision or laparoscopically through the chest. Esophagomyotomy is more successful than forceful dilation, probably because the pressure in the lower sphincter is reduced to a greater extent and more reliably; 80%-90% of patients have good results. With prolonged follow-up, however, some patients develop recurrent dysphagia. Thus, esophagomyotomy does not guarantee a permanent cure. The most important side effect from the more reliable and greater reduction in pressure with esophagomyotomy, is reflux of acid (gastroesophageal reflux disease or GERD). In order to prevent this, the esophagomyotomy can be modified so that it doesn't completely cut the sphincter or the esophagomyotomy may be combined with anti-reflux surgery (fundoplication). Whichever surgical procedure is done, some physicians recommend life-long treatment with oral medications for acid reflux. Others recommend 24 hour esophageal acid testing with lifelong medication only if acid reflux is found.

Botulinum toxin

Another treatment for achalasia is the endoscopic injection of botulinum toxin into the lower sphincter to weaken it. Injection is quick, nonsurgical, and requires no hospitalization. Treatment with botulinum toxin is safe, but the effects on the sphincter often last only for months, and additional injections with botulinum toxin may be necessary. Injection is a good option for patients who are very elderly or are at high risk for surgery, for example, patients with severe heart or lung disease. It also allows patients who have lost substantial weight to eat and improve their nutritional status prior to "permanent" treatment with surgery. This may reduce post-surgical complications.

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See what others are saying

Comment from: ladycaramel14, 55-64 Female (Patient) Published: August 01

As of July 25, 2013, I now know that I have achalasia. Surgery was performed to cut a lining between my esophagus and stomach, which unclogged a blockage between them. I am on the road to a slow recovery. I have been able to eat a solid meal since July 28. My weight will be monitored every day. The steroids have a noticeable side effect, which causes me to have an appetite, loss of sleep, and energy out of this world. I have several medicines to take to each day. Steroids and vitamins are to be taken every day. I also have what is known as adrenal insufficiency.

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Comment from: BaxRex, 45-54 Male (Patient) Published: April 25

I was diagnosed with achalasia 7 years ago. The day before I was to have a myotomy I threw my back out. In desperation I went to a chiropractor. He adjusted my back and told me my achalasia was probably caused from my upper back or neck tightness, caused by stress, which in turn put pressure on my vagus nerve that runs from brain down to my gastrointestinal tract. He adjusted (cracked) my neck and I had immediate relief in my esophagus. The treatment doesn"t work as well as it used to but still works. Every time he cracks my neck (bi-weekly) my esophagus "gurgles". I still have trouble swallowing but it"s much better. I never did the surgery. Hope it works for you.

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