Achalasia

The gullet's valve failing to open. Years of being treated for reflux, when the problem is the opposite.

What it is

A rare condition in which the muscle at the bottom of the oesophagus fails to relax, and the oesophagus itself loses its coordinated squeeze, so food and drink cannot pass into the stomach.

The typical story is years of misdiagnosis. Regurgitation of undigested food is interpreted as reflux, acid-suppressing tablets are prescribed and do nothing, and the person is told they have a sensitive stomach or anxiety. Average time to diagnosis is several years.

The distinguishing feature is **difficulty swallowing both solids and liquids from early on**. Mechanical narrowing, from a stricture or oesophageal cancer, typically affects solids first and liquids later. Achalasia affects both together, and people develop tricks: standing up, arching the back, drinking water to force food down.

Regurgitated material is undigested and not sour, which is another clue that this is not reflux.

Diagnosis is by manometry, which measures the pressures, along with endoscopy and a barium swallow. Endoscopy alone can look normal.

Treatment is mechanical: balloon dilatation, a surgical myotomy, or POEM, an endoscopic procedure. It relieves the obstruction rather than curing the nerve problem, so reflux afterwards is common and follow-up is needed.

There is a small long-term increase in oesophageal cancer risk.

Signs you might notice

Difficulty swallowing both solids and liquids, from early in the illness.

Regurgitation of undigested food, often at night, sometimes onto the pillow.

Chest pain or a feeling of food sticking behind the breastbone.

Coughing or choking at night, and recurrent chest infections from aspiration.

Weight loss.

Heartburn-like symptoms that do not respond to acid-suppressing treatment.

Manoeuvres to help swallowing: standing, stretching the neck, drinking large volumes.

Urgent: any difficulty swallowing needs a two-week referral and endoscopy, because oesophageal cancer must be excluded first.

Also urgent: significant weight loss, recurrent chest infections, or complete inability to swallow.

How it can affect day-to-day life

Eating becomes exhausting and social meals are avoided, often long before anybody understands why.

Night-time regurgitation and aspiration causes recurrent chest infections, and sleeping propped up reduces it substantially.

Malnutrition and weight loss are common by diagnosis, and dietetic input matters.

Being disbelieved for years leaves a legacy: people arrive at diagnosis exhausted and mistrustful, and that deserves acknowledging.

After treatment, most people eat well again, though reflux is a common trade-off and eating slowly and chewing thoroughly remains necessary.

Symptoms can return years later, so long-term follow-up is appropriate rather than discharge after a successful procedure.

Supporting someone well

Take difficulty swallowing seriously and ask for a two-week referral, regardless of age.

Say clearly if liquids are as difficult as solids; that single detail points at this.

Do not accept indefinite acid-suppressing treatment for regurgitation that is not acidic and does not respond.

Ask about manometry if endoscopy is normal but symptoms persist.

Eat slowly, chew thoroughly, sit upright, and drink water with meals.

Sleep propped up to reduce night-time regurgitation and aspiration.

Ask for a dietitian and monitor weight.

Ask about long-term follow-up after treatment; symptoms can recur.

Where to get help

A GP practice for an urgent referral for difficulty swallowing.

Gastroenterology for manometry and treatment; upper gastrointestinal surgery for myotomy.

Guts UK publish information on swallowing and oesophageal conditions.

Royal College of Speech and Language Therapists for swallowing support.