Achalasia is a condition in which the muscle valve at the bottom of the gullet fails to relax, so food and drink collect above it. Pneumatic dilatation uses a large balloon to stretch that valve open. This sheet explains the treatment and how it compares with the alternatives.

What it is, and why you are having it

In achalasia the nerves that tell the lower valve to open have been lost, and the muscle of the gullet body no longer squeezes food downwards. Food and liquid sit above the valve, causing difficulty swallowing, regurgitation of undigested food, chest pain and weight loss. Nothing can restore the nerves, so all treatments work by weakening the valve enough for gravity to move food through.

There are three established ways to do that, and a fourth for people who are not fit for any of them — an injection of botulinum toxin into the valve, which is simple and safe but wears off within months and is generally reserved for that situation. The three are: stretching the valve with a balloon, cutting the muscle through keyhole surgery (Heller myotomy), and cutting it from the inside through an endoscope (POEM). All three work well. Balloon stretching avoids an operation and can be repeated, but is the least durable from a single course — in a five-year trial POEM kept about twice as many people symptom-free without further treatment. The trade-off runs the other way for heartburn, which is substantially commoner after POEM. There is no single best choice — it depends on your age, your type of achalasia, your general health and your own preference. Ask the endoscopy unit to go through the options with you.

Stretching is done in stages. The first session uses a 30 mm balloon. If swallowing is not sufficiently improved, a 35 mm balloon is used two to four weeks later, and occasionally a 40 mm balloon after that. Starting small is deliberate: the risk of tearing the gullet is about three times higher if a 35 mm balloon is used first.

1 the widened gullet · 2 food and fluid held up above the valve · 3 the tight valve · 4 the balloon inflated across it · 5 stomach

Getting ready

• Because achalasia makes food and liquid sit in the gullet, you must fast for longer than for a normal endoscopy. Follow the specific instructions on your appointment letter — you may be asked to take only clear fluids for a day beforehand.
• Blood thinners: this is a higher-bleeding-risk procedure, so contact the unit at least seven days before. See sheet PE-PROC-16.
• You will need a responsible adult to take you home. See sheet PE-PROC-17.
• You must be fit for surgery on the day, because a tear in the gullet occasionally needs an operation to repair it.

On the day

The procedure is done with sedation, often with X-ray guidance. The endoscope is passed down and any retained food is cleared. The balloon is positioned across the valve and inflated to a set pressure for a short time, then deflated and removed. The endoscopist looks at the valve afterwards.

You will be observed for at least four hours. A contrast X-ray of the gullet is no longer done routinely for everyone, but it will be arranged straight away if you have any symptom that suggests a tear.

What are the risks?

Afterwards

You will start with fluids and move to soft food, as instructed. Most people notice swallowing is easier within days.

At your follow-up we will ask you about four things — swallowing, food or liquid coming back up, chest pain, and weight — and combine them into a simple score. It helps us judge whether the treatment is working and whether another stretch is needed.

An acid-suppressing tablet is not given to everyone automatically after balloon stretching; it is started if you develop heartburn or if reflux is demonstrated.

This leaflet is general information and does not replace advice from your own doctor.