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At a glance
- Trouble swallowing always deserves an evaluation, usually starting with upper endoscopy.
- Achalasia is a condition in which the lower esophageal valve doesn’t relax and the esophagus loses its normal squeezing wave.
- High-resolution manometry is the key test for diagnosing achalasia and classifying its type.
- POEM, laparoscopic Heller myotomy, and pneumatic dilation are all effective treatments; the best choice depends on the type and the patient.
Where swallowing problems come from
Swallowing difficulty (dysphagia) is usually grouped by where it happens:
- Starting a swallow — coughing, choking, or food going “down the wrong way” right as you swallow, or food sticking high in the throat. This points toward the throat and upper esophageal sphincter, including a Zenker’s diverticulum, and often involves a speech-language pathologist.
- After the swallow, in the chest — food that seems to hang up behind the breastbone. Causes include narrowing from reflux (strictures), rings, eosinophilic esophagitis, motility disorders such as achalasia, and, less commonly, tumors.
Difficulty with solids only that is gradually worsening suggests a narrowing. Difficulty with both solids and liquids from early on suggests a motility disorder.
Achalasia
In achalasia, nerves in the wall of the esophagus are lost. The lower esophageal sphincter no longer relaxes when you swallow, and the esophagus stops producing its coordinated squeezing wave. Food and liquid collect above the closed valve.
Common symptoms include difficulty swallowing both solids and liquids, regurgitation of undigested food (sometimes at night, with coughing), chest pain, and weight loss. Achalasia is often mistaken for reflux at first, which is one reason manometry is required before any anti-reflux operation.
Diagnosis
- High-resolution manometry confirms the diagnosis and classifies achalasia into type I, II, or III using the Chicago Classification. Type III, the spastic form, has additional strong, premature contractions.
- Barium esophagram, often timed, shows the characteristic narrowing and how well the esophagus empties.
- Upper endoscopy looks for retained food and, importantly, rules out other causes of obstruction, such as a tumor near the valve.
Treatment
The nerve loss in achalasia can’t be reversed, so treatment aims to open the valve so gravity can empty the esophagus. Current ACG and ASGE guidelines describe three main options for people who are fit for them:
| Option | How it works | Considerations |
|---|---|---|
| POEM (per-oral endoscopic myotomy) | The muscle of the valve is divided from inside, through a tunnel made with an endoscope — no skin incisions | Allows for a longer myotomy, less invasive, quicker recovery |
| Laparoscopic Heller myotomy | The muscle is divided from outside through small incisions, usually with a partial fundoplication to limit reflux | Long track record; the partial wrap reduces post-procedure reflux |
| Pneumatic dilation | A balloon stretches and tears the valve muscle during endoscopy | Effective, but may need repeating over time; small risk of perforation |
In a randomized trial comparing POEM with laparoscopic Heller myotomy plus fundoplication, both provided similar symptom relief at two years. Reflux-related inflammation was more common after POEM in that trial; most reflux after POEM is mild and controlled with medication, and experienced surgeons tailor the position and length of the myotomy to reduce it. Botulinum toxin injection can relieve symptoms temporarily and is generally reserved for people who can’t undergo the other treatments.
After any achalasia treatment, follow-up checks symptom relief, esophageal emptying, and reflux.
Treatment of achalasia — including myotomy and POEM — is one of Dr. Speer’s areas of specialized expertise. Learn more in her professional profile.
Other motility and swallowing conditions
- Esophagogastric junction outflow obstruction — the valve doesn’t relax fully, but squeezing is preserved. It may be caused by medications (such as opioids), anatomy, or early achalasia, and needs careful confirmation before treatment.
- Distal esophageal spasm and hypercontractile esophagus — premature or excessively forceful contractions that can cause chest pain and swallowing difficulty.
- Ineffective or absent contractility — weak squeezing, which can follow reflux or occur in conditions such as scleroderma. It matters when choosing any anti-reflux procedure.
- Eosinophilic esophagitis — an allergic-type inflammation that causes food impaction, especially in younger adults. It is diagnosed with biopsies and treated with medications, dietary approaches, and dilation when needed.
Common questions
What causes food to feel stuck?
Common causes include narrowing from reflux, rings, eosinophilic esophagitis, and motility disorders such as achalasia; less often, a tumor. Because causes range from simple to serious, persistent sticking should be evaluated.
Where and how food sticks gives useful clues:
- Solid foods only, gradually worsening — often a narrowing such as a reflux-related stricture or a ring.
- Intermittent sticking, especially with meat or bread, in a younger adult with allergies — raises the possibility of eosinophilic esophagitis.
- Both solids and liquids from the start, with regurgitation of undigested food — suggests a motility disorder such as achalasia.
- Trouble starting a swallow, coughing, or food sticking high in the throat — points to the throat or upper sphincter, including a Zenker’s diverticulum.
An upper endoscopy is usually the first test, with manometry and a barium study added as needed. If food is stuck and you can’t swallow your saliva, seek emergency care.
What is achalasia, and how is it diagnosed?
Achalasia is a loss of nerves in the esophagus that keeps the lower valve from relaxing and stops the normal squeezing wave; it is diagnosed with high-resolution manometry, supported by a barium study and endoscopy.
Achalasia typically causes difficulty swallowing both solids and liquids, regurgitation (often of undigested food, and sometimes at night), chest pain, and weight loss. Because some of these symptoms overlap with reflux, it is frequently mistaken for GERD at first.
Manometry confirms the diagnosis and identifies the type (I, II, or III), which helps guide treatment. A barium esophagram shows how well the esophagus empties, and an upper endoscopy rules out other causes of obstruction near the valve.
How do POEM and Heller myotomy compare?
Both relieve achalasia symptoms very effectively. POEM — done through the mouth with no incisions — has become an increasingly common first choice at experienced centers because it matches Heller myotomy for symptom relief, allows a precisely tailored myotomy, and usually means a quicker recovery. Reflux after POEM is usually mild and manageable.
In a randomized trial comparing the two, symptom relief at two years was similar. The differences are mostly about how the procedure is done and recovery:
- POEM is performed entirely through the mouth, with no abdominal incisions, and recovery is usually quick. The surgeon can choose exactly where to place the myotomy and how long to make it, including a longer myotomy when needed — an advantage in type III (spastic) achalasia, where guidelines favor POEM. POEM is also an option when symptoms return after an earlier Heller myotomy or dilation.
- Reflux after POEM. Because POEM doesn’t add a fundoplication, early trials found reflux more often after POEM. Most of it is mild and well controlled with medication. Experienced surgeons now tailor where the myotomy is placed and how far it extends onto the stomach, and preserve muscle fibers that help keep the valve closed — refinements that early studies suggest lower the risk of reflux. When reflux does occur, it can be treated with medication or, less often, an anti-reflux procedure.
- Heller myotomy is done laparoscopically through small abdominal incisions and has the longest track record. A partial fundoplication is added to limit reflux, and it remains a good option — for example, when a hiatal hernia also needs repair.
The type of achalasia, prior treatments, other medical conditions, and your preferences all shape the choice. Treatment of achalasia, including POEM, is one of Dr. Speer’s areas of specialized expertise.
Sources
- Vaezi MF, et al. ACG Clinical Guidelines — Diagnosis and Management of Achalasia. Am J Gastroenterol. 2020;115(9):1393–1411.
- Khashab MA, et al. ASGE guideline on the management of achalasia. Gastrointest Endosc. 2020;91(2):213–227.
- Yadlapati R, et al. Esophageal motility disorders on high-resolution manometry — Chicago classification version 4.0. Neurogastroenterol Motil. 2021;33(1):e14058.
- Werner YB, et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med. 2019;381(23):2219–2229.
This page is general education. It can’t account for your history, test results, or other conditions, so please discuss your situation with your own clinician.