Non-Surgical Treatment for Achalasia

Unfortunately, there are no medications available to treat achalasia that offer significant or sustained responses. There are two non-surgical treatment options for achalasia:

• Dilatation of the lower esophageal sphincter
• Injection of botulinum toxin

Most patients require an endoscopy, an upper GI series and an esophageal motility test. These tests are needed to confirm the diagnosis, exclude other diseases that also may be present and to look for abnormalities that may alter the therapy chosen or favor one therapy over another.

No matter which therapy is chosen, the patients never eat exactly as they did before.  This is because the lower esophageal sphincter has sustained permanent damage.  Food may get stuck; however this will occur rarely. Patients will not be able to eat or drink lying down.  Nonetheless, they should be able to enjoy almost all meals without distress, regain lost weight, sleep normally and enjoy life again.

Dilatation

Mosher bag dilatation is aimed at stretching the circular muscle of the lower esophageal sphincter area in order to break apart the muscle fibers. If the muscle fibers do not break apart the procedure will not work. The lower esophageal sphincter will return to its abnormal, contracted state and will not allow food to pass. However, if the circular muscle fibers do break, then the lower esophageal area will no longer be able to contract and the patient will be able to swallow.

During the procedure, a narrow tube is passed through the mouth and into the esophagus. An endoscope is also passed down the esophagus so the doctor can locate the area of narrowing and directly observe the procedure. The dilating tube contains a strong balloon which is inflated while its pressure is monitored. The patient can resume a normal diet 6 hours after the procedure.

What are the Results?

Approximately 60 to 80 percent of patients who undergo a dilatation will have good to excellent results in which there is no or minimal difficulty swallowing. Approximately 60 percent will remain well one year later, but that percentage drops to about 50 percent 5 years after the procedure.

Fortunately, patients who initially respond well to dilatation usually respond well when the procedure is repeated. Approximately 20 percent of patients undergoing this treatment will require more than one dilatation to achieve good to excellent long-term results. In contrast, patients who do not respond well the first time are unlikely to respond to a second dilatation. It is important to realize, however, that it may take up to one month for the treatment to work.

What are the Risks?

The principal risk of pneumatic dilatation is perforation of the esophagus. This occurs less than 5 percent of the time. Although many patients with perforation do not require surgery, perforation can be life-threatening. Perforation is suspected when chest pain, back pain, repeated vomiting and/or a rapid heart rate occur after the procedure. For this reason, patients are observed for six hours after the procedure. Other complications are uncommon and usually insignificant. These include bleeding and a blood clot in the wall of the esophagus.

A final complication that must be considered is the development of reflux or gastro-esophageal reflux disease after successful dilatation. Most patients will experience some degree of reflux following the procedure but only a few will develop symptoms of heartburn and chest pain.

Botulinum Injection 

Botulinum is a toxin produced by the bacteria Clostridia botulinum which is responsible for the disease botulism. The toxin affects muscle contraction by stopping the release of chemicals at nerve endings. Used for many years to treat eyelid spasm and other muscle problems, it was first used successfully to treat achalasia in 1994. The technique involves four injections of a small amount of Botulinum toxin in four different areas of the lower esophageal sphincter. The injections are done via an endoscope. The toxin blocks the release of chemicals from nerve endings, thereby making the sphincter relax.

What are the Results?

Botulinum toxin injection produces an excellent result in 90 percent of patients. Unfortunately, the treatment may be short lived; 40 percent of patients who respond to the injection have the result fail within 3 months and only 50 to 60 percent experience relief at 6 months, despite multiple injections. Patients who respond to the first injection often notice less response to each subsequent injection and a shorter period of symptom relief. Although long-term success is seen in some patients, botulinum toxin injection appears most suitable for short term relief.

What are the Risks?

This is a very safe procedure with minimal side effects. It is important to note that botulinum toxin injection does not affect subsequent treatment with other therapies such as dilatation or surgery.

When are Botulinum Toxin Injections Not Recommended?

All patients are candidates for botulinum toxin injections. It is the least invasive and safest of all the treatments available.