Oesophageal achalasia is a rare swallowing disorder that affects the muscular tube connecting your mouth to your stomach, making it increasingly difficult to eat and drink normally over time. While there is no cure for this condition, modern treatment approaches can significantly improve symptoms and help people return to a more comfortable daily life.

Understanding Treatment Goals and Approaches

When someone receives a diagnosis of oesophageal achalasia, the first thing to understand is that treatment focuses on relieving symptoms rather than curing the underlying condition. The main goal is to restore your ability to swallow food and liquids by addressing the malfunctioning valve at the bottom of your oesophagus, known as the lower esophageal sphincter or LES. This ring-shaped muscle normally opens to let food pass into your stomach, but in achalasia, it fails to relax properly, causing food to collect in your esophagus instead.^[1]

Treatment decisions depend on several factors, including how severe your symptoms are, your age, your overall health, and your personal preferences. Some people experience mild symptoms that can be managed with simpler interventions, while others need more definitive procedures to achieve relief. Your healthcare provider will work with you to choose the approach that makes the most sense for your individual situation.^[2]

It’s important to understand that once the esophagus has been damaged by achalasia, the muscles cannot return to working properly on their own. However, symptoms can usually be managed effectively through endoscopy, minimally invasive therapy, or surgery. The landscape of achalasia treatment has changed dramatically in recent years, with new techniques offering alternatives to traditional surgery.^[1]

Both standard treatments approved by medical societies and newer therapies being tested in clinical trials play important roles in managing this condition. The availability of multiple treatment options means that people living with achalasia today have more choices than ever before. Understanding what each treatment involves helps patients make informed decisions about their care.^[7]

Standard Medical and Non-Surgical Treatments

For some patients, particularly those with milder symptoms or who cannot undergo more invasive procedures, medications represent the first line of treatment. Calcium channel blockers such as nifedipine and nitrates are the most commonly used medications for achalasia. These drugs work by relaxing the smooth muscle in the lower esophageal sphincter, reducing its pressure and making it easier for food to pass through.^[11]

The reality is that medications provide only modest benefits. Approximately ten percent of patients experience significant improvement with drug therapy alone. The effect is also temporary, lasting only a short time after each dose, which means medications must be taken regularly. Common side effects include headaches, although these usually improve as your body adjusts to the treatment. Because of these limitations, medications are primarily used in elderly patients who have medical conditions that make other treatments too risky, or as a temporary measure while waiting for more permanent treatment.^[11]

Botulinum toxin injections offer another non-surgical option. During this procedure, performed through an endoscope (a thin, flexible tube with a camera), your doctor injects botulinum toxin directly into the lower esophageal sphincter. The toxin blocks the release of acetylcholine, a chemical messenger that causes muscles to contract, thereby helping the sphincter to relax and open more easily.^[11]

While this treatment is relatively painless and can provide relief, its effectiveness is limited in both strength and duration. Only about thirty percent of patients still experience relief from difficulty swallowing one year after treatment. Most people need repeated injections every few months, with progressively shorter periods of benefit. Additionally, botulinum toxin injections can cause inflammation in the area around the gastroesophageal junction, which may make a later surgical procedure more difficult if needed.^[11]

For these reasons, botulinum toxin is typically reserved for elderly patients who are not good candidates for balloon dilation or surgery. It can be thought of as a bridge treatment, offering temporary symptom relief while patients and doctors plan for more definitive approaches or in cases where other options are not medically appropriate.^[2]

Pneumatic Dilation: Stretching the Sphincter

Pneumatic dilation or balloon dilation is one of the most common treatments for achalasia when performed by qualified specialists. This procedure involves using a specially designed balloon to mechanically stretch open the lower esophageal sphincter. The goal is to rupture some of the muscle fibers in the sphincter while leaving the inner lining of the esophagus intact.^[11]

During the procedure, you’ll be given light sedation to help you stay comfortable. Your doctor passes an endoscope through your mouth and down into your esophagus. Once the endoscope reaches the sphincter, a deflated balloon is positioned precisely at that location. The balloon is then gradually inflated, applying controlled pressure to stretch the muscle ring. The stretching weakens the sphincter’s tight grip, allowing food and liquids to pass more easily into your stomach.^[4]

The success rate for pneumatic dilation ranges from seventy to eighty percent, meaning most people experience significant improvement in their swallowing after the procedure. However, it’s important to understand that this treatment doesn’t always work on the first attempt. As many as fifty percent of patients may require more than one dilation procedure to achieve adequate relief. Your doctor may start with a smaller balloon and progress to larger sizes if needed.^[11]

The main risk associated with pneumatic dilation is perforation, which means creating an unintended tear or hole in the esophagus. This occurs in approximately five percent of cases. While five percent may sound small, it’s a serious complication that requires emergency surgery to repair the perforation and often includes performing a myotomy at the same time. Because of this risk, pneumatic dilation must be performed by experienced specialists who can recognize and manage complications quickly.^[11]

Another consideration is that approximately thirty percent of patients develop pathologic gastroesophageal reflux after the procedure. This happens because the weakened sphincter can no longer prevent stomach acid from flowing back up into the esophagus. While pneumatic dilation improves swallowing, it may create a new problem with acid reflux that requires additional treatment.^[11]

Surgical Treatment: Heller Myotomy

When medications and pneumatic dilation don’t provide adequate relief, or when patients prefer a more permanent solution, surgery becomes the next option. The standard surgical procedure for achalasia is called Heller myotomy. During this operation, the surgeon cuts through the muscle fibers of the lower esophageal sphincter, permanently disrupting its ability to stay tightly closed. Think of it like cutting a circular valve so it opens into a U-shape that can no longer constrict.^[5]

Modern Heller myotomy is typically performed using minimally invasive techniques. Laparoscopic Heller myotomy involves making five small incisions in your abdomen, through which surgical instruments and a camera are inserted. The surgeon uses these instruments to carefully cut the muscle layer of the sphincter while preserving the inner lining of the esophagus. Some centers now also offer robotic-assisted versions of this surgery, which provides even greater precision.^[5]

The success rate for Heller myotomy is impressive, with more than ninety percent of patients experiencing significant relief from their symptoms. Most people stay in the hospital for one to three nights after the procedure and can return to normal activities within a few weeks. The surgery addresses the fundamental problem effectively and provides long-lasting results for the majority of patients.^[5]

Because cutting the sphincter muscle can lead to problems with acid reflux, surgeons usually perform an additional procedure at the same time to prevent this complication. This second procedure, called a fundoplication, wraps part of the stomach around the lower esophagus to create a new valve mechanism that prevents acid from coming back up. Your surgeon will discuss this with you before the operation and explain how it protects you from developing severe heartburn after the myotomy.^[4]

Advanced Treatment in Clinical Development: POEM Procedure

The most exciting advancement in achalasia treatment in recent years is a technique called peroral endoscopic myotomy, or POEM. This innovative procedure represents a significant leap forward in minimally invasive surgery. Unlike traditional Heller myotomy, which requires incisions through the abdominal wall, POEM is performed entirely through the mouth using an endoscope, leaving no external scars whatsoever.^[5]

During the POEM procedure, you’ll be under general anesthesia. Your surgeon inserts an endoscope through your mouth and into your esophagus. Instead of cutting through the abdominal wall, the surgeon creates a small opening in the inner lining of your esophagus and uses the endoscope to create a tunnel between this lining and the muscle layer beneath it. Once inside this tunnel, the surgeon can access and cut the malfunctioning sphincter muscle from the inside. After cutting the muscle, the small opening in the lining is closed with clips or sutures.^[5]

The POEM procedure offers several important advantages over traditional surgery. Because there are no external incisions, patients typically experience less pain and recover more quickly. Many people can go home the same day or after just one night in the hospital, compared to one to three nights for laparoscopic surgery. The procedure takes about ninety minutes, and most patients can return to eating soft foods within a few weeks.^[5]

Accessing the sphincter from inside the esophagus rather than through the abdomen is considered less risky and causes less trauma to the body overall. The procedure provides excellent symptom relief, allowing patients to regain their ability to swallow normally and enjoy meals in social settings without fear of regurgitation or vomiting. For many people, this restoration of normal eating represents a profound improvement in quality of life.^[5]

Currently, the POEM procedure is available at only a small number of specialized centers, primarily in the United States and Europe. Not all hospitals have surgeons trained in this advanced technique. Patients interested in POEM should seek care at high-volume centers of excellence where specialists have extensive experience performing the procedure. As more surgeons receive training, the availability of POEM is expected to expand.^[5]

Choosing Between Treatment Options: Guidelines and Recommendations

In September 2020, the American College of Gastroenterology released updated guidelines for diagnosing and managing achalasia. These guidelines emphasize that treatment selection should be individualized based on several factors: your age, sex, personal preferences, and the expertise available at your local medical institutions. There is no single “best” treatment that works for everyone.^[11]

According to these guidelines, initial therapy options include medical treatment, pneumatic dilation, surgical myotomy, and POEM. All procedures should ideally be performed at high-volume centers of excellence where specialists have significant experience with achalasia. The guidelines recognize that the success of treatment depends not just on the technique itself, but on the skill and experience of the healthcare team performing it.^[11]

For patients who are not suitable candidates for pneumatic dilation or surgery due to other health conditions, botulinum toxin therapy is recommended as an alternative. Similarly, pharmacologic therapy with calcium channel blockers and nitrates can be used for patients who cannot undergo dilation or myotomy and who have not responded well to botulinum toxin injections.^[11]

The guidelines acknowledge that treatment for achalasia should be viewed as an ongoing relationship with your healthcare team rather than a one-time intervention. Regardless of which treatment you choose, follow-up care is essential. Symptoms can return over time, and some patients may need additional treatments. Regular monitoring allows your doctor to assess how well your treatment is working and make adjustments as needed.^[7]

Living with Achalasia: Lifestyle Strategies

Even with successful medical or surgical treatment, most people with achalasia benefit from making adjustments to how they eat and manage their daily routines. These lifestyle changes don’t cure achalasia or replace medical treatment, but they can make living with the condition considerably easier and help prevent complications.^[13]

Eating slowly is perhaps the most important modification you can make. When you take your time with meals, you give your esophagus a better chance to move food downward, even without normal muscle contractions. Chewing food very thoroughly breaks it down into smaller pieces that pass more easily through the malfunctioning sphincter. Many people find that taking small sips of water throughout their meal helps wash food down. Some describe this as “irrigating” their esophagus with fluids.^[14]

The timing of meals matters too. Eating late at night or close to bedtime increases the risk that food will remain stuck in your esophagus while you’re lying down. This can lead to regurgitation during the night, which is not only uncomfortable but dangerous if you inhale food or liquid into your lungs. Most experts recommend finishing your last meal at least two to three hours before going to bed.^[14]

How you sleep can also make a difference. Propping your head up with extra pillows or using a wedge pillow helps gravity assist in moving food from your esophagus into your stomach. This elevated position also reduces the likelihood of nighttime regurgitation and aspiration, complications that can lead to lung infections or aspiration pneumonia.^[14]

Certain foods tend to cause more problems than others, though individual experiences vary widely. There is no universal list of “forbidden foods” because what affects one person may not bother another. Generally speaking, foods that are difficult to chew into a soft consistency, foods that congeal or stick together, foods that cause irritation to the esophagus, and foods that are extremely hot or cold can all create obstacles. Many people learn through trial and error which specific foods or beverages trigger their symptoms.^[12]

Maintaining adequate nutrition can be challenging, especially before treatment or when symptoms are severe. If you’re losing weight or struggling to eat enough, working with a dietician who understands achalasia can be invaluable. They can suggest high-calorie, nutrient-dense foods in soft or liquid forms that provide proper nutrition while being easier to swallow. In rare cases when oral nutrition becomes impossible, feeding tubes may be necessary temporarily to prevent malnutrition.^[18]

Most Common Treatment Methods

• Medications
  • Calcium channel blockers such as nifedipine work by relaxing smooth muscle in the lower esophageal sphincter
  • Nitrates perform a similar muscle-relaxing function
  • Both provide temporary relief and must be taken regularly
  • Approximately 10% of patients benefit significantly from medication alone
  • Common side effects include headaches that usually improve over time
  • Primarily used for elderly patients or those with medical contraindications to other treatments
• Botulinum Toxin Injections
  • Injected directly into the lower esophageal sphincter during endoscopy
  • Blocks release of acetylcholine to help the sphincter relax
  • Provides relief for a few weeks to months
  • Only 30% of patients maintain relief at one year
  • Repeated treatments are necessary but become less effective over time
  • Can cause inflammation that complicates future surgery
  • Reserved for patients who cannot undergo dilation or surgery
• Pneumatic Dilation (Balloon Dilation)
  • Uses a specially designed balloon to stretch open the lower esophageal sphincter
  • Performed during endoscopy under sedation
  • Success rate of 70-80%
  • Up to 50% of patients need multiple dilation sessions
  • Carries approximately 5% risk of esophageal perforation
  • About 30% of patients develop acid reflux afterward
  • Requires experienced specialist to minimize complications
• Laparoscopic Heller Myotomy
  • Surgical cutting of muscle fibers in the lower esophageal sphincter
  • Performed through five small abdominal incisions
  • Over 90% success rate for symptom relief
  • Hospital stay of one to three nights typically required
  • Often combined with fundoplication to prevent reflux
  • Provides long-lasting results for most patients
  • Recovery period of several weeks before returning to normal activities
• POEM (Peroral Endoscopic Myotomy)
  • Advanced minimally invasive procedure performed entirely through the mouth
  • No external incisions or scars
  • Surgeon creates tunnel between esophageal lining and muscle layer
  • Sphincter muscle is cut from inside the esophagus
  • Procedure takes about 90 minutes under general anesthesia
  • Same-day or one-night hospital stay in most cases
  • Less pain and faster recovery compared to traditional surgery
  • Available only at specialized centers with trained surgeons
  • Requires acid-reducing medication for several months post-procedure
• Lifestyle Modifications
  • Eating slowly and chewing food thoroughly
  • Drinking water throughout meals to help wash food down
  • Avoiding eating late at night or close to bedtime
  • Sleeping with head elevated to assist gravity
  • Identifying and avoiding individual trigger foods
  • Working with dieticians for nutritional support
  • These strategies support but do not replace medical treatment