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Health condition · Clinically reviewed

Achalasia, a motor disorder that stops the oesophagus emptying properly.

Progressive dysphagia to solids and liquids, regurgitation and slow weight loss. Diagnosis rests on high-resolution manometry, and definitive treatment now usually means POEM or Heller myotomy.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against BSG, ACG and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including Chicago Classification v4 subtyping and POEM as a mainstream option.

Key facts

Achalasia at a glance.

The essentials, in plain English - what it is, the Chicago v4 subtypes and how it is treated in the UK today.

  • What it is

    A primary oesophageal motor disorder combining impaired lower oesophageal sphincter (LES) relaxation with absent peristalsis in the oesophageal body.

  • Chicago v4 type I

    Classic achalasia. Aperistaltic with no oesophageal pressurisation. Responds well to myotomy or pneumatic dilation.

  • Chicago v4 type II

    Panoesophageal pressurisation on more than 20 per cent of swallows. Best prognosis. Most treatments work well.

  • Chicago v4 type III

    Spastic achalasia with premature contractions. Worst prognosis with dilation or Heller. POEM allows a longer myotomy and is preferred.

  • Gold-standard test

    High-resolution manometry (HRM). Barium swallow and endoscopy support the diagnosis and rule out pseudoachalasia.

  • Modern first-line

    Peroral endoscopic myotomy (POEM) for types I to III, or laparoscopic Heller myotomy with Dor fundoplication for types I and II.

Why this guide matters

The subtype decides the treatment.

Achalasia is uncommon but very treatable. Getting the Chicago v4 subtype right shapes almost every decision that follows.

  • HRM is the gold standard

    Barium and endoscopy support the diagnosis, but high-resolution manometry is what confirms achalasia and defines the subtype.

  • POEM has changed the picture

    Peroral endoscopic myotomy now covers all three subtypes and is especially useful in type III thanks to a tailored, longer myotomy.

  • Follow-up is lifelong

    Post-treatment reflux, Barretts risk and a small squamous cell cancer risk mean surveillance manometry and endoscopy matter for years.

How the diagnosis is made

From first symptoms to a clear plan.

The steps a UK upper GI team will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and dysphagia pattern

    Progressive dysphagia to solids and liquids together, regurgitation of undigested food, chest pain and slow weight loss point strongly to a motor disorder.

  2. 02

    Assessing

    Barium swallow

    The classic birds-beak tapering of the distal oesophagus, delayed emptying and a dilated proximal oesophagus are highly suggestive of achalasia.

  3. 03

    Assessing

    Upper GI endoscopy

    Mandatory to exclude pseudoachalasia from a distal oesophageal or cardia malignancy, and to assess for candida, retained food and mucosal changes.

  4. 04

    Confirming

    High-resolution manometry

    The gold-standard test. Confirms impaired LES relaxation with an elevated integrated relaxation pressure and defines the Chicago v4 subtype.

  5. 05

    Confirming

    Chicago Classification subtyping

    Type I (aperistaltic, no pressurisation), type II (panoesophageal pressurisation) and type III (spastic, premature contractions) each guide a slightly different treatment path.

  6. 06

    Preparing

    Eckardt score and fitness review

    A baseline Eckardt symptom score is used to track response, alongside a review of surgical or endoscopic fitness for the chosen therapy.

  7. 07

    Preparing

    Shared decision on therapy

    POEM, laparoscopic Heller with Dor fundoplication and pneumatic dilation are all reasonable in the right patient. Subtype, age and reflux tolerance shape the choice.

Typical timeline: first clinic visit to a settled treatment plan in weeks, not months.

Symptoms

What achalasia actually feels like.

The classic mix of dysphagia to both solids and liquids, regurgitation and slow weight loss - plus the features that mean it is time to look harder for another cause.

  • Dysphagia to solids and liquids

    Unlike a mechanical stricture, food and drink both stick from early on. A defining feature.

  • Regurgitation of undigested food

    Bland, non-acidic material regurgitates hours after eating, sometimes at night, with a risk of aspiration.

  • Retrosternal chest pain

    Cramping chest pain, particularly common in type III (spastic) achalasia and sometimes mistaken for cardiac pain.

  • Slow weight loss

    Gradual, unintentional weight loss as swallowing becomes harder. Rapid loss should raise concern for malignancy.

  • Heartburn-like symptoms

    Fermentation of retained food can mimic reflux. True acid reflux is uncommon before treatment.

  • Nocturnal cough or aspiration

    Overnight regurgitation into the airway can cause chronic cough, recurrent chest infections or aspiration pneumonia.

  • Difficulty belching

    A tight LES stops air escaping normally, leaving a persistent feeling of fullness or bloating after meals.

  • Red flag - rapid weight loss over 50

    Short symptom history, marked weight loss and older age raise the possibility of pseudoachalasia from a hidden malignancy.

Treatment

How achalasia is treated in the UK.

POEM and laparoscopic Heller myotomy with Dor fundoplication are the definitive options. Pneumatic dilation, botox and medication have narrower, more selective roles.

  • Peroral endoscopic myotomy (POEM)

    Endoscopic tunnelling myotomy of the LES and distal oesophagus. Modern first-line for types I to III and the preferred option for type III thanks to a tailored, longer myotomy. See our own POEM treatment page for detail.

  • Laparoscopic Heller myotomy

    The historical gold standard for types I and II. Surgical division of the LES muscle, almost always combined with a partial (Dor) fundoplication to limit post-operative reflux.

  • Dor fundoplication

    A partial anterior wrap added to Heller myotomy. Reduces post-myotomy reflux while preserving oesophageal emptying.

  • Pneumatic balloon dilation

    Graded, stepwise balloon dilation of the LES under fluoroscopy. Selective use in types I and II when POEM or Heller are not suitable. Carries a small perforation risk.

  • Botulinum toxin injection

    Endoscopic injection into the LES. Temporary benefit for a few months. Reserved for frail patients or as a bridge, and it can complicate later myotomy.

  • Nitrates and calcium-channel blockers

    Sublingual nitrates or nifedipine before meals can offer modest, short-lived relief. Side effects and limited efficacy make them a secondary option.

  • Sildenafil

    Occasionally trialled for spastic features via smooth-muscle relaxation. Limited evidence and off-label in this setting.

  • Oesophagectomy

    A last-resort option for end-stage sigmoid oesophagus after failure of definitive treatment. Undertaken in specialist upper GI centres only.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, international consensus and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your upper GI consultant knows your history and manometry findings and can tell you which parts apply to you. If in doubt, get seen.

  • British Society of Gastroenterology (BSG). Guidance on oesophageal motility disorders.

  • American College of Gastroenterology (ACG). Clinical guideline: diagnosis and management of achalasia.

  • Chicago Classification v4.0 of oesophageal motility disorders.

  • ISDE and ESGE position statements on POEM and Heller myotomy.

  • NICE interventional procedures guidance on peroral endoscopic myotomy for achalasia.

Red flags

When achalasia needs urgent attention.

Most cases are stable and follow a planned pathway. These are the situations that need faster escalation and a specialist opinion.

  • Rapid weight loss and short history

    A short symptom history with marked weight loss, especially over the age of 50, needs urgent endoscopy and cross-sectional imaging to exclude pseudoachalasia.

  • Aspiration or recurrent chest infection

    Overnight regurgitation causing pneumonia, chronic cough or hospital admissions is an indication for definitive treatment rather than watchful waiting.

  • Complete food impaction

    Sudden inability to swallow saliva or fluids after a meal needs same-day endoscopic assessment.

  • New or worsening chest pain

    Cardiac causes should always be excluded first. Spastic type III achalasia can mimic angina.

  • GI bleeding or anaemia

    Not typical of achalasia and warrants urgent endoscopy to look for another cause, including oesophageal cancer.

  • Suspected perforation after dilation

    Severe chest or upper abdominal pain, fever or surgical emphysema after pneumatic dilation is an emergency needing immediate imaging and surgical review.

  • Post-treatment reflux

    Persistent heartburn after POEM or Heller can drive Barretts oesophagus. It needs PPI therapy and surveillance endoscopy.

  • End-stage sigmoid oesophagus

    Massive dilation with a tortuous, sigmoid-shaped oesophagus after years of untreated disease may need specialist assessment for oesophagectomy.

  • Long-standing untreated disease

    Increased lifetime risk of oesophageal squamous cell carcinoma and, after treatment, adenocarcinoma. A clear reason for ongoing follow-up.

Living with it

A treatable condition, with a clear pathway.

Four things that make the biggest difference day to day - simple mealtime habits, sensible sleeping position, planned follow-up and taking cancer surveillance seriously.

A quiet reminder

Definitive treatment usually helps, but does not always cure.

Symptoms can drift back over years, and post-treatment reflux is common. Regular manometry and endoscopy pick up problems early.

  1. 01 Meals

    Eat sitting upright, slowly

    Small mouthfuls, thorough chewing and warm water with meals help the oesophagus empty by gravity.

  2. 02 Sleep

    Elevate the head of the bed

    Raising the head of the bed and avoiding food for three hours before sleep reduces nocturnal regurgitation and aspiration risk.

  3. 03 Follow-up

    Manometry and endoscopy over time

    Regular symptom review, timed barium studies and periodic endoscopy help detect recurrence, reflux and any premalignant change early.

  4. 04 Cancer risk

    Take surveillance seriously

    Long-standing achalasia raises squamous cell risk, and post-treatment reflux raises adenocarcinoma risk via Barretts. Attend all follow-up endoscopies.

Frequently asked

Everything we get asked about achalasia.

Quick answers on diagnosis, Chicago v4 subtypes, POEM versus Heller and long-term cancer risk.

  • What is achalasia?

    A primary oesophageal motor disorder in which the lower oesophageal sphincter fails to relax properly and the body of the oesophagus loses its coordinated peristalsis. Food and liquid then struggle to pass into the stomach, causing progressive dysphagia, regurgitation and weight loss.

  • How is achalasia diagnosed?

    The pathway usually starts with a barium swallow (classic birds-beak sign) and an upper GI endoscopy to exclude a malignancy that can mimic achalasia. High-resolution manometry is the gold-standard test and confirms impaired LES relaxation while classifying the disease as Chicago v4 type I, II or III.

  • What are the Chicago Classification subtypes?

    Type I is aperistaltic with no oesophageal pressurisation. Type II shows panoesophageal pressurisation in more than 20 per cent of swallows and has the best prognosis. Type III is spastic achalasia with premature contractions and generally the worst prognosis, so POEM (which allows a longer myotomy) is usually preferred.

  • Is POEM better than Heller myotomy?

    Both are highly effective for types I and II, with similar symptom control at medium-term follow-up. POEM is generally preferred for type III achalasia because the length of the myotomy can be tailored. POEM tends to cause more post-operative reflux than Heller with Dor fundoplication, so choice depends on subtype, patient factors and local expertise.

  • When is pneumatic dilation or botox used?

    Pneumatic balloon dilation is a reasonable, selective option in types I and II when POEM or Heller are not suitable. Botulinum toxin injection into the LES gives short-lived benefit and is mainly reserved for frail patients or as a bridge, because it can complicate later myotomy.

  • Does achalasia increase cancer risk?

    Yes. Long-standing achalasia is associated with an increased lifetime risk of oesophageal squamous cell carcinoma from chronic stasis, and post-treatment reflux can drive Barretts oesophagus and adenocarcinoma. That is why regular manometry, endoscopy and, where relevant, Barretts surveillance are so important.

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