Achalasia cardia is a primary oesophageal motility disorder in which the lower oesophageal sphincter (LOS) fails to relax during swallowing, combined with absent peristalsis in the oesophageal body. The pathology stems from progressive degeneration of inhibitory ganglion cells in the myenteric plexus, resulting in unopposed sphincter tone and functional obstruction at the gastro-oesophageal junction. It affects both sexes equally most commonly presenting in the third to fifth decade of life. Secondary achalasia known as pseudoachalasia must always be excluded, as it can be caused by infiltrating junctional tumours or in endemic regions, Chagas disease.
Symptoms
The hallmark symptom is progressive dysphagia initially to solids, then liquids often accompanied by regurgitation of undigested, non-acidic food, particularly at night, carrying a significant risk of aspiration pneumonia. Patients frequently report retrosternal chest discomfort, heartburn-like pain from oesophageal spasm, and gradual weight loss as oral intake diminishes. The condition is commonly misdiagnosed as GORD early on due to overlapping symptoms, leading to diagnostic delay. In advanced untreated disease, the oesophagus becomes massively dilated and tortuous termed sigmoid oesophagus representing end-stage disease.
Diagnosis
Upper GI Endoscopy is the first-line investigation, revealing a dilated, food-filled oesophagus with a tight, puckered cardia and is essential to exclude pseudoachalasia and underlying malignancy. Barium swallow demonstrates the classic "bird's beak" appearance smooth tapering of the distal oesophagus with proximal dilatation. High-Resolution Oesophageal Manometry (HRM) is the gold standard, confirming elevated LOS relaxation pressure and absent peristalsis. HRM further classifies achalasia into Type I (classic), Type II (pan-oesophageal pressurisation best prognosis) and Type III (spastic most refractory), guiding treatment selection.
Treatment
Laparoscopic Heller's Myotomy (LHM) is the surgical gold standard a longitudinal division of the LOS muscle fibres extending 6 cm onto the oesophagus and 2–3 cm onto the stomach, consistently achieving symptom relief in 85–95% of patients. A partial fundoplication (Dor or Toupet) is routinely added to prevent post-myotomy reflux. Pneumatic Balloon Dilation offers an effective non-surgical alternative with 60–80% success, though recurrence and perforation risk are higher. POEM (Peroral Endoscopic Myotomy) an incisionless endoscopic technique achieves equivalent results to LHM and is particularly effective for Type III achalasia at specialist centres. Botulinum toxin injection into the LOS provides temporary relief for patients unfit for definitive intervention, with effects lasting 6–12 months before repeat treatment is needed.