When Swallowing Becomes Difficult: Understanding Achalasia and POEM

Swallowing is something most people rarely think about. However, for people living with achalasia, this simple process can become increasingly difficult, affecting their comfort, nutrition and quality of life.

Achalasia is a disorder of the food pipe, or oesophagus that disrupts normal swallowing. The muscles responsible for moving food towards the stomach fail to function properly, while the muscle at the lower end of the oesophagus does not relax, as it should. Consequently, food and liquids struggle to pass into the stomach.

Many patients describe the sensation of food being stuck in the chest after swallowing. Others experience food or liquids coming back up, chest discomfort or unexplained weight loss. Because these symptoms often develop gradually, they may be mistaken for indigestion or acid reflux, leaving the condition untreated for years.

Diagnosing achalasia

Accurate diagnosis is essential to determining the most appropriate treatment. Doctors use several tests to assess how the oesophagus functions and rule out other possible causes of swallowing difficulties.

These investigations may include an upper endoscopy, in which a thin, flexible camera is passed through the mouth to examine the food pipe and stomach. Oesophageal manometry measures the strength and coordination of the muscles in the food pipe, while a barium swallow involves an X-ray examination after the patient drinks a special liquid that helps doctors observe how material moves through the oesophagus.

The specialist determines which tests are necessary based on the patient's symptoms and clinical assessment. Establishing the diagnosis helps guide decisions about treatment and whether a procedure such as Peroral Endoscopic Myotomy (POEM) may be appropriate.

Understanding POEM as a treatment option

Traditionally, achalasia has been treated using surgery or other procedures designed to relax the tight muscle at the lower end of the oesophagus. Advances in endoscopy have introduced another option: POEM, a minimally invasive procedure used primarily to treat achalasia.

Performed entirely through the mouth using a flexible endoscope equipped with a camera and specialised instruments, POEM works by carefully dividing the affected muscle fibres. This relaxes the tight muscle, allowing food and liquids to pass more easily into the stomach.

The procedure is carried out under anaesthesia. The endoscope is passed through the mouth into the oesophagus, where a small opening is made in the inner lining. A tunnel is then created within the wall of the oesophagus, allowing the specialist to reach and divide the muscle fibres. Once this is complete, the opening is closed using small endoscopic clips.

Because POEM is performed from within the food pipe, it does not require external surgical incisions. This distinguishes it from conventional surgery, which may involve cuts through the skin to reach the affected muscles.

The Aga Khan University Hospital, Nairobi, has recently introduced this advanced procedure, expanding access to a treatment option that remains relatively rare in the region.

Who may benefit from POEM?

POEM is primarily considered for patients diagnosed with achalasia, although it may also be suitable for certain other disorders affecting the movement of the oesophagus. However, it is not necessarily the best treatment for everyone.

The choice of treatment depends on several factors, including the type of achalasia, the patient's overall health, individual circumstances and whether previous treatment has been undertaken. POEM may be particularly beneficial for some patients with type III achalasia, which is characterised by abnormal muscle contractions or spasms affecting a longer section of the food pipe.

Preparing for the procedure

Before undergoing POEM, patients receive a medical assessment to establish whether the procedure is appropriate and whether anaesthesia can be administered safely.

Preparation involves following the healthcare team's instructions on eating and drinking before the procedure, including when these must stop. Patients are also advised on which medications should be continued and which may require adjustment or temporary discontinuation.

It is important to inform the medical team about all medications and supplements being taken. These preparations help the team assess the patient and plan for the procedure appropriately.

Recovery and returning to normal activities

Following POEM, patients are monitored by the medical team. Food and drinks are gradually reintroduced according to the patient's condition and the doctor's recommendations.

Recovery varies from person to person. The timing of return to work, exercise and other daily activities depends on individual progress and the nature of the activities involved. Patients should follow the medical team's advice on when it is safe to resume their normal routines.

Follow-up appointments are equally important. They allow the specialist to assess healing, monitor symptoms and address any concerns that may arise after treatment.

Effectiveness, recurrence and risks associated with POEM

POEM can significantly improve swallowing difficulties and related symptoms in many appropriately selected patients. Research indicates that its benefits can continue over the long term, although outcomes vary between individuals.

Nevertheless, some patients may continue to experience symptoms or develop them again after treatment. Persistent or recurrent difficulty swallowing and regurgitation may be associated with achalasia that has not fully resolved or has returned. In other cases, the symptoms may be related to acid reflux. Further assessment is necessary to identify the cause and determine the appropriate management.

As with any medical procedure, POEM also carries potential risks. These include bleeding, infection, injury to the oesophagus and complications related to anaesthesia. Acid reflux may also occur after the procedure. Patients should discuss the potential benefits and risks with their specialist before making a treatment decision.

When to seek specialist care

Anyone experiencing persistent difficulty swallowing, frequent regurgitation, chest discomfort or unexplained weight loss should seek medical attention. These symptoms should not be dismissed as ordinary indigestion, particularly when they persist or worsen over time.

A gastroenterology specialist can investigate the underlying cause, establish an accurate diagnosis and determine whether POEM or another treatment option is appropriate.

The message is simple: persistent swallowing difficulties should never be ignored. Early diagnosis and appropriate treatment can significantly improve quality of life. For many patients living with achalasia, POEM offers an effective, minimally invasive treatment option that can help restore comfort and confidence when eating and drinking.

 By Dr Nkeng Ajua, Consultant Gastroenterologist, Aga Khan University Hospital