What actually happens
When you swallow, the oesophagus pushes food downwards in a coordinated wave while the valve separating it from the stomach relaxes to let it through. In achalasia both are lost: the oesophagus stops contracting usefully and that valve does not open.
The result is that food accumulates above it. Over the years the oesophagus dilates and the problem becomes harder to treat, which is why it should not be left.
The symptoms, and why diagnosis comes late
- Difficulty swallowing both solids and liquids, which is a fairly characteristic feature
- Regurgitation of undigested food, sometimes hours later or at night when lying down
- A sensation of food held behind the breastbone
- Chest pain that can be mistaken for a cardiac problem
- Progressive weight loss
- Night-time cough or recurrent chest infections from material entering the airway
Why years pass before diagnosis
Patients adapt without noticing: eating slowly, drinking plenty of water, avoiding certain foods, leaving the table. And because gastroscopy can be normal in early stages, the picture is easily labelled as reflux or anxiety for years.
How it is diagnosed
Three things are needed, and none replaces the others.
- Gastroscopy, essential to exclude a tumour at the junction with the stomach producing the same picture
- High-resolution oesophageal manometry, the test that confirms the diagnosis and defines the subtype
- Contrast radiology, useful for assessing the shape and degree of oesophageal dilation
The subtype shown by manometry is not an academic detail: it determines which treatment works best in your particular case.
Treatment: POEM
Achalasia is not cured by medication. Treatment consists of opening the valve that will not relax, and three effective routes exist today: pneumatic balloon dilation, laparoscopic surgery (Heller myotomy) and POEM.
POEM — per-oral endoscopic myotomy — divides the muscle of the valve from the inside, endoscopically, with no external incision. Access is through the mouth, a tunnel is created in the oesophageal wall and the muscle layer blocking passage is cut.
- No scars and no abdominal incisions
- Short admission and faster recovery than surgery
- Allows the length of the cut to be matched to the achalasia subtype, particularly useful in type III
- Also an option where previous treatments have failed
Available in the hospital itself
Endoscopic treatment of achalasia with POEM is performed at Hospital Ruber Juan Bravo, so diagnosis, manometry and treatment are coordinated without referral elsewhere.
My work in this area
I am co-author of a review of POEM as a new endoscopic treatment for achalasia, published in the Revista Española de Enfermedades Digestivas and produced alongside colleagues at Hôpital Nord in Marseille, one of the European reference centres for the technique.
I have also worked on the study of oesophageal shortening measured by high-resolution manometry in patients with primary achalasia, presented at the national meeting of the Spanish Association of Gastroenterology.