Is Your Acid Reflux Really Achalasia?

How to know the difference

Illustration of food stuck before emptying from esophagus - achalasia

You know heartburn all too well. Maybe it happens after too much salsa. Or after any big meal. Or when you lie down.

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Acid, partly digested food and other stomach contents creep up into your esophagus, causing the inside of your chest to burn like a jalapeño.

Most of the time it’s just acid reflux, or gastroesophageal reflux disease (GERD), which affects about 1 in 5 Americans. But for about 1 in 100,000 Americans per year, it’s actually a different condition, called achalasia.

Knowing which condition you have is important because acid reflux and achalasia are treated differently. If untreated (or treated incorrectly), you may continue to suffer with symptoms — and continued damage to your esophagus can become irreversible.

What’s the difference?

Both acid reflux and achalasia happen when the “door” from your esophagus to your stomach is broken. With acid reflux, the door doesn’t close when it should. With achalasia, the door doesn’t open when it should.

The door is called the lower esophageal sphincter. It’s a ring of muscle that should be squeezed shut most of the time. When you swallow, it should relax and open to let food into your stomach and then squeeze shut again.

“You may experience a small amount of acid reflux during this process,” says gastroenterologist Scott Gabbard, MD. “Up to one hour of acid reflux per day is actually considered normal.”

If you have achalasia, your lower esophageal sphincter doesn’t open. Whatever you swallow gets stuck at the bottom of your esophagus, which can cause heartburn, just like acid reflux.

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It’s not clear what causes achalasia, but it has to do with the nerves that tell the sphincter when to open. Something causes those nerves to disappear, possibly an immune system response to a virus.

How to tell the conditions apart

Because the conditions have similar symptoms, it’s not uncommon for people with achalasia to be treated for acid reflux — sometimes for years.

“If stomach contents come back up after you’ve swallowed them, most of the time it’s acid reflux,” says Siva Raja, MD, PhD, Surgical Director of the Center for Esophageal Diseases. “But if you have difficulty swallowing and feel like your food gets stuck in your esophagus, you should be tested to rule out conditions like achalasia and even esophageal cancer.”

A gastroenterologist may do an endoscopy to look in your esophagus or conduct a barium swallow or esophageal manometry to see how your esophagus is working.

Feeling like your food doesn’t go down to your stomach can be a sign of achalasia, but not always, says Dr. Gabbard. Acid reflux can cause ulcers at the bottom of your esophagus, which can cause food to get stuck, too.

What treatments will work

If you have acid reflux, treatments usually involve:

  • Dietary changes. Avoiding high-fat foods, caffeine, acidic foods, peppermint and other potentially acid-producing items may help reduce your symptoms — although it’s not scientifically proven, notes Dr. Gabbard.
  • Weight loss. Reducing your body mass index by as little as three points has been shown to reduce acid reflux symptoms.
  • Smoking cessation. Nicotine is thought to relax the lower esophageal sphincter, allowing stomach contents to escape back up into the esophagus.
  • Repositioning while you sleep. Laying on your left side with your head elevated 6 to 8 inches may reduce nighttime reflux.
  • Medications. You can take antacids (which neutralize acid) or proton pump inhibitors (which stop acid from being produced) long-term.

If you have achalasia, acid reflux treatments typically won’t relieve your symptoms. Instead, your doctor may recommend:

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  • Surgery. The tried-and-true treatment is a Heller myotomy, a surgery that cuts an opening in the lower esophageal sphincter. It can be done laparoscopically/robotically (through tiny holes in your abdomen). Recent advances allow doctors to do the procedure endoscopically (down your throat). “Recovery after the endoscopic procedure is as short as a few days because there are no incisions,” says Dr. Raja. “But with the laparoscopic procedure, you can have an additional procedure (partial fundoplication) that can lower your risk of acid reflux. The best surgery for you depends on how the muscles in your esophagus contract, your overall health, whether you’ve had a myotomy before, and other factors.”
  • Pneumatic dilation. In this outpatient procedure, a balloon is inflated in your esophagus to stretch open the sphincter muscle. Some patients need to repeat the procedure every few years.
  • Botox® injection. Botox relaxes the sphincter muscle, causing it to open. This procedure is done endoscopically, through the mouth, and needs to be repeated about once a year.

Because achalasia is so rare, you may need to be referred to an experienced medical center for accurate diagnosis and treatment.

“I recommend different treatments for different patients,” says Dr. Gabbard. “The same treatment isn’t best for everyone.”

When to see a doctor

If you have heartburn and regurgitation once a week or less, try lifestyle changes and over-the-counter acid reflux medications first. If your symptoms don’t improve, see a doctor to be evaluated for achalasia or other conditions.

See a doctor sooner if you:

  • Have heartburn twice a week or more.
  • Feel that food is getting stuck in your esophagus.

“Achalasia is a rare chronic disease,” says Dr. Raja. “Having regular follow-ups with an experienced specialist is important for long-term relief from symptoms and to ensure your esophagus is working as well as it can.”

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