Achalasia is a disorder that affects how the esophagus moves. The main symptom is dysphagia, or difficulty swallowing. Patients may have trouble swallowing liquids or feel like food is stuck in their esophagus. Some patients will experience nasal regurgitation, where fluid comes up into the back of the mouth or out through the nose.
“Difficulty swallowing and regurgitation are two signs that should alert a primary care physician to a motility disorder and to consider achalasia as a possibility,” says gastroenterologist Shailender Singh, MD, MBBS. “Chest pain is another less common symptom, as is weight loss which can develop over time.”
Achalasia vs. GERD
Unlike achalasia, the main sign of gastroesophageal reflux disease, or GERD, is a heartburn sensation. If a patient has GERD, food will usually go down normally. After eating, acid comes back up causing a burning feeling in the chest.
When evaluating a patient, the PCP should ask if they feel pain when swallowing or a burning feeling after eating. This will tell you if the patient may have GERD or a disorder like achalasia.
Diagnosing esophageal motility disorders
If a patient has trouble swallowing and a motility disorder is suspected, a PCP can refer them to a gastrointestinal (GI) specialist for further testing. A barium test may help diagnose later stages of achalasia, but at earlier stages, the test can look normal. For this reason, most GI specialists prefer an upper endoscopy (EGD) to look for the underlying cause of the dysphagia.
An endoscopy is ordered to review inside the esophagus, stomach and small bowel for abnormalities. The doctor may also take a small tissue sample, or biopsy, if needed.
If the endoscopy does not show a blockage, a doctor may order a high-resolution manometry (HRM). This test uses sensors to measure muscle contractions in the esophagus when a patient swallows.
“An HRM test would be done after endoscopy,” explains Dr. Singh. “If no mechanical obstruction is found, and biopsies of the esophagus are normal, most GI doctors will consider an HRM for further evaluation.”
Referring patients for POEM or Heller
Heller myotomy is a type of surgery. The surgeon makes a small incision in the skin and cuts the lower esophageal sphincter muscle to help food and liquids go down.
In POEM, which stands for per oral endoscopic myotomy, a doctor inserts a scope through the mouth and into the esophagus. They observe the images on a monitor. An incision is made to access the esophageal sphincter muscle to help with swallowing. Most patients go home the next day.
“At first, there was a lot of debate about the long-term efficacy of POEM, and therefore Heller was still being done,” says Dr. Singh. “Today, studies have proven POEM to have long-term efficacy. Therefore, it has become the recommended first-line treatment for achalasia. However, we still offer Heller surgery to patients who want to consider all the options.”
Outcomes and safety profile of POEM
The Nebraska Medicine team has done more than 50 POEM procedures with excellent results.
“Our patients haven’t had any major complications, such as bleeding, perforation or infection,” says Dr. Singh. “Other studies have shown that 80% to 90% of patients who undergo the POEM procedure for achalasia are symptom-free 10 years later.”
After their POEM procedure, patients are placed on a liquid diet for a few days, then eat soft foods another three to five more days. By day 10, they can return to their normal diet. Recovery after POEM is otherwise normal. Once a patient is discharged, they feel just as they would from any other endoscopy.
Role of primary care in long-term follow-up and post-procedure surveillance
The Nebraska Medicine Esophageal Diseases and Motility Clinic is the only clinic in the region with a full team to treat swallowing disorders. This team includes specialists in gastroenterology, surgery, laryngology, speech pathology and nutrition.
A primary care physician can refer patients with swallowing trouble to the clinic. There, patients can discuss treatment options, including both Heller and POEM, with GI specialists and surgeons.
After a patient has been discharged, a nurse practitioner from the clinic will follow up with a phone or video call at two weeks, three months, six months, and one year after treatment.
For more information about Nebraska Medicine esophageal diseases and motility clinic, call 402.559.4015.