Achalasia is treated through a range of options, from medications and injections to minimally invasive procedures that open the lower esophageal sphincter, the muscular valve between your esophagus and stomach. The best approach depends on the severity of your symptoms, your overall health, and which subtype of achalasia you have. For most people who are healthy enough for a procedure, some form of surgical or endoscopic intervention offers the most durable relief.
Understanding What’s Happening
In achalasia, the nerves controlling the lower esophageal sphincter deteriorate, leaving the valve unable to relax properly when you swallow. Food and liquid back up in the esophagus instead of passing into the stomach. The condition is diagnosed with a test called high-resolution manometry, which measures pressure inside the esophagus. A resting pressure above 15 mmHg at the sphincter is the key diagnostic threshold.
There are three subtypes. Type I involves minimal esophageal contractions and a dilated, floppy esophagus. Type II shows intermittent pressurization across the entire esophagus with each swallow. Type III features spastic, poorly coordinated contractions. The subtype matters because it influences which treatment works best. Type II generally responds well to most interventions, while Type III can be harder to manage and may benefit from treatments that allow a longer cut along the esophageal muscle.
Medications: A Temporary Measure
Oral medications are the least effective treatment for achalasia, but they can provide short-term relief when procedures aren’t an option. Two types of drugs are commonly used: nitrates and calcium channel blockers. Both work by relaxing smooth muscle in the sphincter, though neither addresses the underlying nerve damage.
Isosorbide dinitrate, taken under the tongue at a dose of 5 to 10 mg about 10 to 15 minutes before each meal, can reduce sphincter pressure by roughly 66% for about 90 minutes. Nifedipine, also taken sublingually at 10 mg before meals, reduces pressure by 30 to 40% but only lasts about 60 minutes. Side effects like headaches, dizziness, and low blood pressure are common, and many people find the relief insufficient. Medications are generally reserved for patients who can’t tolerate other treatments or who need a bridge while waiting for a procedure.
Botox Injections
Injecting botulinum toxin directly into the sphincter muscle during an upper endoscopy is a quick, low-risk option. A needle is passed through the endoscope and 100 units are injected in four spots around the valve. The toxin temporarily paralyzes the muscle, allowing it to relax.
About 78% of patients feel better within the first month. The problem is durability. By six months, only 58% still have meaningful relief, and by one year that drops to around 49%. Most people need repeat injections, and the effect tends to diminish with each round. Repeated injections can also cause scarring that makes future surgery more difficult. Botox is best suited for elderly patients or those with serious health conditions that make surgery too risky.
Pneumatic Dilation
Pneumatic dilation uses a specially designed balloon to physically stretch and tear the sphincter muscle fibers. During an endoscopy, the deflated balloon is positioned across the sphincter and then inflated to a controlled pressure. The procedure is typically done as an outpatient visit, and you can usually go home the same day.
Success rates range from 55% to 70%, with symptom improvement reported in 50% to 89% of patients. Some people need more than one session, with progressively larger balloons used if the first attempt doesn’t provide enough relief. The main risk is esophageal perforation, which occurs in 2% to 12% of cases and carries a 1% to 2% mortality rate. Because of this risk, a CT scan or contrast swallow study is typically performed shortly after the procedure to check for leaks.
Pneumatic dilation works well for patients with Type I or Type II achalasia and is a reasonable alternative for those who prefer to avoid surgery. Results tend to be less durable than surgical options, with some patients requiring repeat dilations over the years.
Heller Myotomy
Laparoscopic Heller myotomy has been the surgical standard for achalasia for decades. The surgeon makes several small incisions in the abdomen and uses a camera and thin instruments to cut the muscle fibers of the lower esophageal sphincter, permanently weakening it so food can pass through. The procedure is almost always paired with a partial fundoplication, where the top of the stomach is wrapped partially around the lower esophagus to create a valve that prevents acid reflux.
Long-term results are strong. One large study found that 84.3% of patients were free of symptoms 10 years after surgery, with 81.4% still doing well at 20 years. Meta-analyses confirm 5-year and 10-year remission rates around 76% to 80%. The Dor fundoplication, a front-facing partial wrap, is the most commonly studied version paired with the myotomy.
Hospital stays are usually one to two days. The surgery carries small risks of esophageal perforation during the muscle cut and, less commonly, incomplete relief that requires additional treatment. For patients under 60 with good surgical fitness, Heller myotomy is one of the most reliable long-term solutions.
POEM: The Endoscopic Alternative
Peroral endoscopic myotomy, or POEM, accomplishes the same goal as a Heller myotomy but without any external incisions. The entire procedure is performed through the mouth using an endoscope. The surgeon creates a tunnel within the esophageal wall and cuts the inner muscle layer from the inside, then closes the entry point with small clips.
POEM slightly outperforms Heller myotomy in short-term swallowing improvement: 93.5% of POEM patients reported relief at 12 months compared to 91% after surgery. At 24 months, the numbers were 92.7% and 90%, respectively. POEM also allows the surgeon to extend the muscle cut higher up the esophagus, which can be particularly helpful for Type III achalasia with its spastic contractions.
The tradeoff is reflux. Because POEM doesn’t include a fundoplication, acid reflux is significantly more common afterward. On pH monitoring, 47.5% of POEM patients showed abnormal acid exposure compared to 11.1% after Heller myotomy. Visible erosive damage to the esophagus was found in 22.4% of POEM patients versus 11.5% after Heller myotomy. Most post-POEM reflux can be managed with acid-reducing medication, but it’s a lifelong commitment you should factor into your decision.
How Treatment Differs by Subtype
Type II achalasia responds best to nearly every intervention, making it the most straightforward to treat. Pneumatic dilation, Heller myotomy, and POEM all produce good outcomes for this subtype.
Type I achalasia, with its dilated and poorly contracting esophagus, generally does well with Heller myotomy or POEM. Pneumatic dilation can work but may need to be repeated.
Type III is the most challenging. The spastic contractions extend well above the sphincter, so treatments that only target the valve itself may leave significant symptoms behind. POEM has an advantage here because the muscle cut can be extended much further up the esophagus to address the spasm. Many specialists consider POEM the preferred first-line treatment for Type III achalasia.
Recovery and Diet After a Procedure
Whether you have a Heller myotomy or POEM, the recovery diet follows a gradual progression designed to let your esophagus heal before you challenge it with solid food.
For the first one to two days, you’ll stick to clear liquids: water, decaf tea, clear juices like apple or grape, broth, gelatin, and ice pops. Avoid carbonated beverages. From roughly day two through day seven, you can move to full liquids like milk, strained cream soups, plain yogurt, cream of wheat, and nutritional shakes. Starting around week two, soft foods are introduced: scrambled eggs, oatmeal, mashed potatoes, soft fish, pasta, and steamed vegetables.
Most people can return to a regular diet within about eight weeks of surgery. Foods that previously caused trouble because of achalasia are worth reintroducing slowly over the following months. Some items may still be difficult, but many patients find they can eat a much wider variety of foods than they could before treatment. Eating slowly, chewing thoroughly, and drinking fluids with meals are habits that tend to help long-term, even after a successful procedure.
Choosing the Right Treatment
The decision between treatments comes down to several factors: your age, your achalasia subtype, your willingness to accept reflux risk, and your access to experienced specialists. POEM and Heller myotomy both require high-volume centers with surgeons or endoscopists who perform these procedures regularly, and outcomes are significantly better at experienced centers.
For younger, healthy patients with Type I or II achalasia, Heller myotomy with fundoplication offers excellent long-term control with lower reflux rates. For Type III patients or those seeking a less invasive approach, POEM provides slightly better short-term swallowing results at the cost of higher reflux. Pneumatic dilation is a solid non-surgical option, especially for Type II, though repeat procedures may be needed. Botox and medications fill an important role for patients who aren’t candidates for anything more aggressive, but they don’t change the course of the disease.