7 Common Achalasia Symptoms You Should Know About

Achalasia is a rare disorder affecting the esophagus, the tube that carries food from your mouth to your stomach. This condition occurs when the lower esophageal sphincter (LES) fails to relax properly during swallowing, and the esophagus loses its ability to push food downward. As a result, food and liquids have difficulty passing into the stomach, leading to various uncomfortable symptoms that can significantly impact quality of life.

Understanding the symptoms of achalasia is crucial for early diagnosis and management. This condition typically develops gradually, with symptoms becoming more pronounced over time. Many people live with mild symptoms for years before seeking medical attention. In this article, we’ll explore the seven most common symptoms of achalasia, their underlying causes, and frequently asked questions about this esophageal disorder.

1. Dysphagia (Difficulty Swallowing)

Dysphagia, or difficulty swallowing, is the hallmark symptom of achalasia and typically the first sign that something is wrong. This symptom affects nearly 100% of people with achalasia and progressively worsens over time.

Initially, patients may notice difficulty swallowing solid foods, particularly dry or dense items like bread, meat, or rice. As the condition advances, the problem extends to liquids as well, which is unusual for most other swallowing disorders. Patients often describe a sensation of food getting “stuck” in the chest, typically behind the breastbone.

People with achalasia commonly develop compensatory strategies to help food pass through, such as:

• Drinking large amounts of water with meals
• Eating very slowly and chewing food thoroughly
• Straightening or arching the back
• Raising their arms above their head
• Standing or walking around during meals

The severity of dysphagia can fluctuate from day to day or even meal to meal, with stress and anxiety often making symptoms worse.

2. Regurgitation of Undigested Food

Regurgitation is another prominent symptom of achalasia, affecting approximately 60-91% of patients. Unlike vomiting, regurgitation is a passive process where undigested food and saliva come back up from the esophagus without the forceful contractions associated with vomiting.

This regurgitation typically contains food that was consumed hours earlier, still recognizable and undigested because it never reached the stomach. The material usually doesn’t taste acidic or bitter like typical reflux because it hasn’t been exposed to stomach acid.

Key characteristics of regurgitation in achalasia include:

• Occurs more frequently when lying down or bending over
• Can happen several hours after eating
• May cause nocturnal coughing or choking episodes
• Can lead to aspiration (food entering the airways)
• Often worse after large meals

Many patients report waking up at night with food on their pillow or experiencing episodes while sleeping, which can be particularly distressing and disruptive to sleep quality.

3. Chest Pain

Chest pain is a common symptom of achalasia, reported by 25-64% of patients. This pain can be alarming because it often mimics cardiac chest pain, leading many people to initially seek emergency care thinking they’re having a heart attack.

The chest pain associated with achalasia has several distinct features:

Location and Character: The pain is typically located behind the breastbone (retrosternal) and can range from a dull ache to sharp, squeezing sensations. Some patients describe it as pressure or tightness in the chest.

Triggers: Pain often occurs during or shortly after eating and drinking, as the esophagus struggles to push food through the tight lower sphincter. It can also occur spontaneously, even when not eating.

Duration: Episodes may last from a few minutes to several hours. The pain tends to be more severe in the early stages of the disease when the esophageal muscles are still attempting to contract forcefully.

Relief: Some patients find that regurgitation or belching provides temporary relief, as this releases the pressure built up in the esophagus.

The chest pain often becomes less frequent as the disease progresses and the esophagus becomes more dilated and less capable of strong contractions.

4. Heartburn and Reflux-like Symptoms

Although achalasia is fundamentally different from gastroesophageal reflux disease (GERD), approximately 40-60% of patients report heartburn-like symptoms. This can make diagnosis challenging, as patients and physicians may initially mistake achalasia for the more common GERD.

The “heartburn” experienced in achalasia differs from typical GERD in important ways:

Origin: The burning sensation comes from fermentation of stagnant food in the esophagus rather than from stomach acid refluxing upward. Bacteria break down trapped food, producing acidic byproducts that irritate the esophageal lining.

Response to Treatment: Unlike GERD, achalasia-related heartburn doesn’t respond well to standard acid-reducing medications like proton pump inhibitors or antacids. If heartburn persists despite adequate acid suppression therapy, achalasia should be considered.

Associated Symptoms: The reflux-like symptoms in achalasia are usually accompanied by other features like dysphagia for both solids and liquids, which is less common in pure GERD.

Patients may also experience a sour or bitter taste in their mouth, particularly after regurgitation episodes.

5. Weight Loss

Unintentional weight loss occurs in 35-91% of achalasia patients and can be one of the more concerning symptoms that prompts medical evaluation. The weight loss results from multiple factors related to the difficulty of getting food into the stomach.

Reduced Food Intake: Many patients unconsciously reduce their food consumption because eating becomes uncomfortable, time-consuming, and anxiety-producing. The fear of symptoms like chest pain, choking, or regurgitation can lead to avoiding meals or eating very small portions.

Dietary Modifications: Patients often eliminate foods that are harder to swallow, which may include high-calorie, nutrient-dense foods like meats, nuts, and bread. This selective avoidance can lead to inadequate caloric intake.

Malnutrition Risk: In advanced cases, significant weight loss can lead to malnutrition and related complications. The average weight loss in achalasia patients ranges from 5 to 15 kilograms (11 to 33 pounds), though some patients experience more dramatic losses.

Social Impact: The difficulty and embarrassment associated with eating can cause patients to avoid social dining situations, further limiting their food intake and affecting their quality of life.

It’s important to note that not all patients with achalasia experience significant weight loss, especially in early stages or when symptoms develop very gradually.

6. Chronic Cough and Respiratory Symptoms

Respiratory symptoms affect approximately 30-40% of achalasia patients and result from aspiration of regurgitated food and saliva into the airways. These symptoms can sometimes overshadow the gastrointestinal complaints and lead to misdiagnosis.

Nocturnal Cough: Many patients experience coughing fits at night when lying flat, as gravity no longer helps keep food in the esophagus. Regurgitated material can trickle into the throat and airway during sleep, triggering intense coughing episodes.

Aspiration Pneumonia: Repeated episodes of aspiration can lead to recurrent lung infections or pneumonia. Patients may experience fever, chest congestion, and difficulty breathing. Some individuals develop chronic lung inflammation from ongoing micro-aspirations.

Hoarseness and Throat Clearing: Constant throat irritation from regurgitated material can cause chronic hoarseness, frequent throat clearing, and a sensation of mucus in the throat.

Asthma-like Symptoms: Some patients develop wheezing and shortness of breath that may be mistaken for asthma. However, these respiratory symptoms don’t respond well to typical asthma medications.

Halitosis: Bad breath can occur due to fermentation of stagnant food in the dilated esophagus, along with oral hygiene challenges related to frequent regurgitation.

Pulmonary complications are more common in patients with advanced achalasia and significant esophageal dilation.

7. Hiccups and Belching

While less common than other symptoms, persistent hiccups and excessive belching can be troublesome manifestations of achalasia, affecting approximately 10-20% of patients.

Hiccups: Chronic or recurrent hiccups in achalasia result from irritation of the phrenic nerve, which controls the diaphragm. The dilated, food-filled esophagus can press against this nerve, triggering involuntary diaphragmatic contractions. Episodes may be prolonged and difficult to stop with typical home remedies.

Belching: Patients often experience excessive belching or burping as trapped air and gas accumulate in the esophagus above the closed lower sphincter. This gas can come from:

• Swallowed air during eating and drinking
• Fermentation of stagnant food by bacteria
• Carbonated beverages that release gas

Relief Mechanism: Some patients discover that intentionally inducing belching provides temporary relief from the sensation of fullness or pressure in the chest. However, forceful belching attempts can sometimes worsen symptoms or trigger regurgitation.

Social Embarrassment: Uncontrollable hiccups and frequent belching can be socially embarrassing, causing patients to avoid social situations and contributing to the psychological burden of the disease.

These symptoms, while not as debilitating as dysphagia or regurgitation, can significantly impact quality of life and may be early warning signs of achalasia in combination with other symptoms.

Main Causes of Achalasia

The exact cause of achalasia remains largely unknown, but researchers have identified several factors that contribute to the development of this condition. Understanding these causes can help explain why the esophagus loses its normal function.

Nerve Degeneration

The primary pathological feature of achalasia is the progressive loss of ganglion cells in the myenteric plexus, the network of nerves between the muscle layers of the esophagus. These nerve cells are responsible for coordinating the muscular contractions that move food downward and for relaxing the lower esophageal sphincter.

When these nerve cells degenerate and die, the esophagus loses its ability to perform normal peristalsis (wave-like contractions), and the lower sphincter remains abnormally tight, creating the characteristic features of achalasia.

Autoimmune Response

Increasing evidence suggests that achalasia may be an autoimmune condition in which the body’s immune system mistakenly attacks the nerve cells of the esophagus. Several findings support this theory:

• Inflammatory cells are often found in the esophageal tissue of achalasia patients
• Some patients have antibodies against their own esophageal tissue
• Achalasia occasionally occurs alongside other autoimmune disorders
• There may be genetic predisposition in some individuals

Viral Infections

Some researchers believe that viral infections might trigger the autoimmune response or directly damage esophageal nerves. Viruses that have been investigated include measles virus and human papillomavirus (HPV), though no definitive causal relationship has been proven.

Genetic Factors

While achalasia is not typically inherited, genetic factors may increase susceptibility. Familial cases do occur, and certain genetic variations have been associated with increased risk. However, most cases appear to be sporadic without clear family history.

Secondary Causes

In some cases, achalasia-like symptoms result from other underlying conditions, referred to as “secondary achalasia” or “pseudoachalasia,” including:

• Cancers at the gastroesophageal junction that mimic achalasia
• Chagas disease (caused by Trypanosoma cruzi parasite, primarily in Latin America)
• Amyloidosis or sarcoidosis affecting the esophagus
• Post-surgical complications

These secondary causes must be ruled out during the diagnostic process, as their treatment differs significantly from primary achalasia.

Frequently Asked Questions

How is achalasia diagnosed?

Achalasia is diagnosed through several tests including esophageal manometry (which measures pressure and muscle contractions in the esophagus), barium swallow X-ray (showing characteristic “bird’s beak” narrowing), and upper endoscopy (to rule out other conditions and examine the esophagus directly). Esophageal manometry is considered the gold standard for diagnosis.

Is achalasia a serious condition?

Yes, achalasia is a serious chronic condition that requires medical management. While not immediately life-threatening, untreated achalasia can lead to significant complications including severe malnutrition, aspiration pneumonia, and increased risk of esophageal cancer. However, with appropriate treatment, most patients can achieve significant symptom relief and maintain good quality of life.

Can achalasia go away on its own?

No, achalasia does not resolve spontaneously. It is a progressive condition that typically worsens over time without treatment. The nerve damage that causes achalasia is permanent, so some form of intervention is necessary to manage symptoms. Early diagnosis and treatment are important to prevent complications and preserve esophageal function.

At what age does achalasia typically develop?

Achalasia can occur at any age, including in children, but it most commonly develops in adults between the ages of 25 and 60 years. There appears to be a slight increase in incidence in people over 60. The condition affects men and women equally, with no significant gender preference.

Does stress cause achalasia?

Stress does not cause achalasia, but it can worsen symptoms in people who already have the condition. Anxiety and stress can increase muscle tension, including in the esophagus, making swallowing more difficult. Many patients report that their symptoms are more severe during stressful periods. Managing stress through relaxation techniques may help reduce symptom severity.

What foods should be avoided with achalasia?

Patients with achalasia should generally avoid dry, dense, or sticky foods that are difficult to swallow, including tough meats, dry bread, rice, peanut butter, and sticky desserts. Acidic or spicy foods may irritate the esophagus. Carbonated beverages can increase gas and pressure. Instead, patients often find softer, well-moistened foods easier to tolerate, and drinking water with meals can help food pass through more easily.

Can achalasia cause cancer?

Long-standing achalasia is associated with a slightly increased risk of esophageal cancer, particularly squamous cell carcinoma. The risk increases with the duration of the disease, with estimates suggesting the cancer risk is about 10-30 times higher than in the general population. However, the overall absolute risk remains relatively low. Regular monitoring and treatment of achalasia are important for reducing this risk.

Is achalasia hereditary?

Achalasia is generally not considered a hereditary condition. Most cases occur sporadically without family history. However, rare familial cases have been reported, and there may be genetic factors that increase susceptibility. If you have a family member with achalasia, your risk is slightly elevated compared to the general population, but it remains uncommon.

Can you live a normal life with achalasia?

With proper treatment and management, most people with achalasia can maintain a good quality of life. While achalasia cannot be cured, various treatment options can effectively relieve symptoms and allow patients to eat more comfortably. Many patients successfully manage their condition long-term and continue working, traveling, and participating in normal activities. Regular follow-up with healthcare providers is important for optimal management.

When should I see a doctor about swallowing difficulties?

You should see a doctor if you experience persistent difficulty swallowing, especially if it affects both solid foods and liquids, if you have frequent regurgitation of undigested food, unexplained weight loss, or chest pain. Any swallowing problem lasting more than a few days or that is progressively worsening warrants medical evaluation. Early diagnosis of achalasia leads to better outcomes and can prevent complications.

References:

• Mayo Clinic – Achalasia
• National Institute of Diabetes and Digestive and Kidney Diseases – Achalasia
• MedlinePlus – Achalasia
• Johns Hopkins Medicine – Achalasia
• StatPearls – Achalasia
• UpToDate – Achalasia