Patients typically present after the age of 20 with progressive difficulty in swallowing, regurgitation, bad breath and cough. Patients often complain of chest pain and a sensation of heartburn which may reflect pathological oesophageal motility. Weight loss is an inconsistent feature and older patients with difficulty in swallowing and weight loss should be suspected of underlying malignancy until proven otherwise.

Gastroscopy can be unremarkable in the early stages but oesophageal dilation and oesophagitis due to food stasis may be apparent in established cases.

Oesophageal manometry should be done in patients with dysphagia and no apparent mechanical cause. In Achalasia this shows increased resting pressure in the LOS with failure of LOS relaxation on swallowing. Oesopageal bosy motility is also frequently abnormal.

Photograph: Endoscopic view of a dilated oesophagus with chronic oesophagitis in a patient with chalasia of the cardia.

Treatment is designed to reduce the LOS pressure and this can be achieved by smooth muscle relaxant drugs, balloon dilation, botox injections and surgical myotomy. Reduction in LOS pressure can lead to pathological acid reflux and a Fundoplication may be added to the myotomy to reduce post operative gastro-oesophageal reflux.

Surgical myotomy (laparoscopic Hellers cardio-myotomy) is the most effective treatment and some studies have suggested the best long term symptomatic results are achieved my combining the myotomy with a partial anti-reflux fundoplication. Treatment needs to tailored to the individulal patients situation.

More information on controversies in treatment of Achalasa of the Cardia