What is achalasia?
Achalasia affects the esophagus, the tube that carries food and drinks from your mouth to your stomach. In achalasia, the muscles of the esophagus do not squeeze food downward normally, and the lower esophageal sphincter (LES), a ring of muscle that acts as a valve between the esophagus and stomach, does not relax as it should. As a result, food and liquid can become trapped in the esophagus instead of passing into the stomach.
Achalasia is uncommon, affecting roughly 1 to 2 people per 100,000 each year, but it can occur at any age.
What are the symptoms of achalasia?
Symptoms usually develop slowly over months to years and tend to worsen if the condition is not treated.
Common symptoms include:
- Trouble swallowing food or liquids (dysphagia).
- Food or liquid coming back up into the mouth (regurgitation).
- A feeling that food is stuck in your chest.
- Chest pain or discomfort.
- Heartburn-like symptoms.
- Coughing or choking, especially when lying down at night.
- Weight loss without trying.
- Food or liquid going into the airway (aspiration), which can lead to lung infections.
What causes achalasia?
The exact cause is not known. Achalasia develops when the nerves that control the muscles of the esophagus become damaged. Because of this:
- The muscles of the esophagus cannot push food toward the stomach normally.
- The LES does not open fully to let food pass into the stomach.
Achalasia is not caused by stress or acid reflux, although some of its symptoms may feel similar to reflux.
How is achalasia diagnosed?
Your gastroenterologist may use several tests to diagnose achalasia and rule out other conditions.
Tests may include:
A thin, flexible tube with a camera is used to look inside your esophagus and stomach and to make sure another problem is not causing your symptoms. Learn more about upper endoscopy.
For this test, you drink a liquid that coats your esophagus while X-rays are taken to see how food and liquid move.
This test measures how well the muscles of your esophagus work and how the LES opens and closes. It is the most important test for diagnosing achalasia and for identifying which “type” (type I, II, or III) you have, which helps guide treatment.
What are the different types of achalasia?
Achalasia has three types, numbered I, II, and III. You will need to do a swallowing pressure test called esophageal manometry, which shows how the muscles of the esophagus behave when you swallow.
In all three types, the valve at the bottom of the esophagus (the lower esophageal sphincter, LES) fails to open properly, and the normal squeezing wave that pushes food down is lost. The types simply differ in what the esophagus muscle does instead. Knowing the type matters because it helps predict how well treatment will work and which treatment is best.
In plain terms:
- Type I (often called “classic” achalasia): The esophagus has essentially gone quiet — the muscle has little or no squeezing activity, so food mostly sits and drains by gravity. This is often a later stage, once the esophagus has stretched out and become weak.
- Type II (achalasia with pressurization): This is the most common type. The esophagus can’t push food down in a coordinated wave, but the whole tube squeezes and builds up pressure at once (imagine squeezing a closed toothpaste tube from all sides). This is usually an earlier stage and tends to respond best to treatment.
- Type III (“spastic” achalasia): The least common and most difficult type. Instead of quiet or uniform pressure, the esophagus has strong, uncoordinated, cramping contractions (“spasms”). These often cause more chest pain, and this type generally responds less well to some standard treatments.
Why the type guides treatment
- For types I and II, the three main definitive treatments — pneumatic dilation (the balloon stretch), laparoscopic Heller myotomy (surgery), and POEM (endoscopic myotomy) — all work about equally well, and the choice comes down to your preferences, your other medical factors, and the expertise available at your center.
- For type III, POEM is generally preferred, because it allows the surgeon to make a longer cut that addresses the spastic segment; the balloon stretch works poorly for this type.
How is achalasia treated?
There is no cure for achalasia, but treatment can help relieve symptoms and improve swallowing by reducing the tightness of the LES so food can pass more easily.
Your treatment plan depends on:
- The type of achalasia you have.
- Your age and overall health.
- Your symptoms.
- The treatment options and expertise available at your center.
The main procedures — pneumatic dilation, laparoscopic Heller myotomy, and POEM — work about equally well for type I and type II achalasia. POEM is often preferred for type III achalasia. Your care team can help you weigh the benefits and risks of each.
A surgeon cuts the tight LES muscle so it relaxes. This is usually done together with a partial “wrap” (fundoplication) to reduce acid reflux afterward.
An elemental diet is a nutritionally complete liquid formula that is absorbed early in the digestive tract. It can help reduce bacteria in the small intestine and may be used as an alternative to antibiotics.
POEM is a minimally invasive procedure performed through an endoscope. During POEM, the doctor cuts the tight LES muscle from inside the esophagus. AGA guidance notes that POEM is an effective treatment for many people with achalasia and may be the preferred treatment for some forms of the condition (type III achalasia). Because it does not include an anti-reflux wrap, acid reflux is more common afterward and may require long term acid-reducing medication.
Botox may be injected into the LES to help it relax. Its effect usually only lasts a few months, and injections often need to be repeated, so it is generally reserved for patients who cannot safely undergo the longer lasting treatments above.
Muscle relaxing pills are generally the least effective option and are used mainly for patients who are not candidates for other treatments.
Eating with achalasia
Changes in eating habits can help reduce symptoms.
- Soups
- Yogurt
- Oatmeal
- Smoothies
- Mashed vegetables
- Tender meats
- Soft casseroles
Some people with severe symptoms may need pureed or liquid foods for a time.
- Take small bites and chew thoroughly.
- Eat slowly.
- Sip liquids during meals to help wash food down.
- Add sauces or gravies to moisten foods.
- Try room-temperature or warm beverages.
- Avoid lying down right after eating.
- Wait about 3 hours after a meal before going to bed.
- Consider eating smaller meals more often throughout the day.
- Raising the head of your bed may help keep food and liquid from coming back up at night.
Living with achalasia
Most people manage achalasia successfully with treatment and follow-up care. Because some treatments can increase acid reflux, your provider may recommend additional monitoring or acid-reducing medicine to protect your esophagus.
Contact your healthcare provider if you:
- Have worsening trouble swallowing.
- Lose weight without trying.
- Frequently cough or choke while eating.
- Develop chest pain.
- Continue to have symptoms after treatment.
Questions to ask your healthcare team
- What type of achalasia do I have?
- Which treatment is best for me?
- What are the benefits and risks of each treatment option?
- Will I need follow-up testing?
- Should I make changes to my diet?
- What symptoms should prompt me to call the office?
Reviewed by
Jessica D. Korman, MD
Capital Digestive Care, Washington, DC
AGA Patient Education Advisor
September 2026