Dear Doctor: Can viral infections, such as COVID, have a role in triggering achalasia?

DEAR DR. ROACH: I have achalasia, which I understand is quite rare. Can you tell me the cause, and is it in any way related to the COVID vaccination? I heard from one professional doctor that it might be. I had excessive coughing before, during and long after recovery from COVID. Could it have damaged my esophagus? The report stated that “the lumen of [my] esophagus was severely dilated.”

Of the various treatments for achalasia, which do you recommend? Is there any chance that I could return to eating a normal diet? Currently, I have been on a strictly liquid diet without any meat or bread and have lost considerable weight. — G.S.

ANSWER: Achalasia is an uncommon swallowing problem due to damage of the nerve cells within the esophagus itself. The major symptom is “dysphagia,” which just means “bad eating.” Most people note a gagging sensation that occurs with both solids and liquids, sometimes with regurgitation of undigested food. Heartburn and chest pain are also common.

The esophagus requires coordinated muscular activity to move food along efficiently. That coordination comes from nerve cells in the esophagus. It is not exactly known what causes nerve cells to degenerate in people with achalasia.

Of course, with millions of people infected by COVID, there are going to be a few who will develop achalasia just by chance after the infection, and it’s possible that COVID might have had a bad effect on those nerve cells. I read several studies showing it is plausible that COVID infection might have damaged those nerve cells.

One study found the COVID virus in the surgical specimens of people who both acquired achalasia after COVID infection and who required surgery to help control their symptoms, but not in the control group of patients. In addition, other studies showed that new diagnoses of achalasia were much greater than expected after a COVID infection. Combined, these studies provided moderately strong evidence that viral infections such as COVID might have a role in triggering achalasia.

There are several types of treatments for achalasia. The major goals of treatment are to improve swallowing symptoms; prevent worsening of the dilation of the esophagus; and relieve other symptoms such as chest pain. Unfortunately, we don’t have any treatments that can restore damaged or dead nerve cells, so a cure is impossible at this time.

Dietary changes are critical to avoid problem foods, which may vary from person to person. Medications, unfortunately, are not particularly effective, but one treatment is surgery to reduce muscular tension at the end of the esophagus and allow food into the stomach. This can be done endoscopically (through a flexible tube in the mouth) or laparoscopically (via a surgical instrument placed through the skin of the abdomen). Dilation of the esophagus by a balloon is another treatment, as is an injection of botulinum toxin (Botox).

The decision of which procedure to use is made by your gastroenterologist based on your particular characteristics and any medical conditions you have. However, because your esophagus is severely dilated, surgery might be recommended.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.

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