Achalasia – How to Treat Swallowing Difficulty


Most people have probably never heard the term achalasia.

This is a disease in which the lower esophageal sphincter does not open properly. Which can lead to serious swallowing difficulties.

Only a few clinics in Germany offer selected diagnostic and therapy options. One of them is the Gastroenterology Clinic at the University Hospital Gießen and Marburg at the Marburg site.

Professor Ulrike Denzer, head of the endoscopy section ,

Private lecturer Dr. Michaela Müller, Head of Functional Diagnostics. In 2018, the clinic moved into completely new premises in order to treat outpatients and inpatients in the best possible way using the latest technology. “For us, it’s not just about pure diagnostics. Instead, we see ourselves as a therapeutic unit,” says Prof. Denzer in an interview with the RHÖN health blog.

One of the treatment focuses of the clinic is the minimally invasive endoscopic removal of early tumors, but also the minimally invasive peroral endoscopic myotomy (POEM), which can help people with swallowing difficulties very effectively.

In an interview with the RHÖN health blog, the two experts explain the esophageal sphincter problem in detail, explain old and new treatment methods – and report on their experiences.

Miss Dr. Müller, could you briefly classify and explain the clinical picture of achalasia?

dr Müller: As humans, we normally have an upper and a lower sphincter in the esophagus. The lower one ensures that food does not slide back out of the stomach. As soon as we start chewing and swallowing, this muscle gets the message: “You have to open it now so that the food can get through the esophagus into the stomach!” This opening mechanism is disturbed in people suffering from achalasia.

Do you know what is causing this malfunction?

dr Müller: Unfortunately not so far. However, extensive studies suggest that genetically mediated autoimmune processes may play an important role. A viral infection, for example, could be a trigger. But here, too, there is still a lack of clarity in medicine. The fact is that those nerves that are supposed to ensure the necessary relaxation in the sphincter muscle are disturbed. With the consequences mentioned for the people affected.

How common is achalasia?

dr Müller: Statistics assume two to three new cases per 100,000 inhabitants per year, but the number of unreported cases is likely to be significantly higher. Simply because there are many people with swallowing difficulties who tolerate their symptoms for years without being diagnosed. We as humans are very adaptable. Many patients have practically learned to live with a sphincter that is only slightly open. By chewing well and drinking a lot with meals – and in doing so something like “compensating for” the problems. But of course it’s not pleasant.

How do you get a diagnosis?

dr Müller: In the case of swallowing difficulties, endoscopy plays a major role in order to rule out that a tumor or inflammation is not the cause of the problem. The first examination is therefore usually a gastroscopy, since the disease is often described as inconspicuous, especially in the early stages.

What other options are there?

dr Müller: A pressure measurement, the so-called manometry of the esophagus using a probe with 36 pressure measuring points. It provides us with valuable information about the act of swallowing. A color value can be assigned to each print, and we can then evaluate this pattern very precisely – and draw conclusions. At this point we then realize, for example, that the aforementioned lower sphincter is not working properly. Of course, with this method we can also detect other movement disorders of the esophagus, which can also lead to swallowing difficulties or chest pains, since the food is not transported into the stomach as desired by the necessary, coordinated contractions.

And how do you treat them?

dr Müller: Since we don’t know thewager81, as mentioned, we can’t treat it either, but at least we can alleviate the symptoms. We do this by allowing food to pass freely through the lower esophageal muscle and back into the stomach.

How does this work?

Prof. Denzer: We are talking about a tried and tested treatment method here, the so-called endoscopic balloon dilatation, in which an endoscope is inserted into the entrance to the stomach. The defective sphincter muscle is then ruptured using a thick balloon – in order to improve the so-called “passage through” of food. However, this procedure only works with special forms of achalasia, namely types 1 and 2. In addition, the result usually does not last very long. Patients often have difficulty swallowing again after a few months or a year.

What other methods are there beyond that?

Prof. Denzer: The surgical method, also known as the “Heller myotomy”. This is a laparoscopy in which the lower esophageal sphincter is incised from below. A sling is also placed to prevent food from flowing back. This method has also been tried and tested for a long time.

The latest type of surgery is much gentler, namely minimally invasive. We are one of the few clinics in Germany to offer our patients this treatment.

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How exactly does it work?

Prof. Denzer: This involves the endoscopic severing of the muscle, which we call peroral endoscopic myotomy, or POEM for short. This is an operation that is not carried out from the outside, as has been the case up to now, but from the inside, and it is very targeted. However, the principle is conceptually similar to that of surgery. And very effective. Here, a tunnel is created through the esophagus into the stomach, and then the muscles are divided endoscopically in a targeted manner. Namely in those places that the graphic pressure point display shows us.

Do you also carry out this newer treatment method in the clinic? And what are your previous experiences with the POEM?

dr Müller: Yes, for about two years. In addition to diagnostics and treatment, we also take care of aftercare and long-term care for our patients. The feedback is really good and I’ve also become a big fan of the treatment, precisely because it’s very gentle and very effective.


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