J Ayurveda Integr Med. 2015 Jan-Mar; 6(1): 41–44.

PMCID: PMC4395928
doi: 10.4103/0975-9476.146556 PMID: 25878463

Ayurvedic management of achalasia

Sanjeev Rastogi and Priyanka Chaudhari1

Department of Panchakarma, Annals of Ayurvedic Medicine, State Ayurvedic College and Hospital, Lucknow, Uttar
Pradesh, India
1
Editorial Office, Annals of Ayurvedic Medicine, State Ayurvedic College and Hospital, Lucknow, Uttar Pradesh,
India
Address for correspondence: Prof. Sanjeev Rastogi, Department of Panchakarma, State Ayurvedic College,
Tulsi Das Marg, Lucknow - 226 003, Uttar Pradesh, India. E-mail: [email protected]

Received 2014 Jun 27; Revised 2014 Aug 2; Accepted 2014 Sep 3.

Copyright : © Journal of Ayurveda and Integrative Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share
Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Abstract
Achalasia is an esophageal motor disorder characterized by sustained lower esophageal sphincter
contraction and reduced esophageal peristalsis. This pathology eventually results in symptoms like
dysphagia, regurgitation and occasional chest pain related to food intake. This is an uncommon
disorder of unexplained etiology; however viral, autoimmune and neurodegenerative causes are often
afflicted to its manifestation. As per the current state of knowledge, achalasia is considered to be a
chronic incurable condition. The treatment options offered here primarily aim at reducing the tone of
lower esophageal sphincter by pharmacologic, endoscopic or surgical means. We are presenting here a
case of achalasia with two years of symptomatic history of food regurgitation, dysphagia and heart
burn without any noticeable response from allopathic medicines. The patient was subsequently kept
under ayurvedic therapy considering the symptoms caused by vata impairment and hence requiring
vatanulomana and reduction in esophageal muscle tone as the primary management. The patient was
kept under suggested Ayurvedic therapy and followed-up for 3 months. A symptom-free follow-up in
this case was noticed after completion of 1 month of Ayurvedic therapy.

Keywords: Achalasia, amlapitta, ayurveda, gastroesophageal reflux disease, Vatanulomana

INTRODUCTION
Achalasia is a primary esophageal motor disorder causing insufficient lower esophageal sphincter
(LES) relaxation and reduced esophageal peristalsis. The symptoms produced thereby are dysphagia,
both with solids and liquids, occasional chest pain related with food intake and regurgitation. Achalasia
is an uncommon condition of unknown etiology where the pathology is proposed to be of a viral,
autoimmune or neurodegenerative nature.
Achalasia is commonly misdiagnosed as gastroesophageal reflux disease (GERD) owing to symptoms
like dysphagia, chest pain, weight loss and heart burn. The distinctive features of achalasia are
regurgitation of bland undigested food or saliva, substernal chest pain and dysphagia, both with solid
and liquid, in the absence of any stricture or tumor.[1]

The American College of Gastroenterology (ACG) recommends that achalasia must be suspected in
those with dysphagia to solids and liquids and in those with regurgitation unresponsive to an adequate
trial of proton pump inhibitor (PPI) therapy.[2]

Achalasia can be diagnosed manometrically by identifying insufficient relaxation at LES,

radiographically by observing loss of peristalsis, esophageal dilation and minimal LES opening causing
bird's beak appearance and also by seeing poor emptying of barium in a barium swallow study.[3] It
can also be diagnosed endoscopically by seeing the dilated esophagus, with retained saliva, liquid and
undigested food particle in the absence of any stricture or tumor.

Achalasia occurs equally in men and women, with an incidence of 1 in 100,000 and a prevalence of 10
in 100,000 annually.[4] The peak incidence occurs between 30 and 60 years. The pathological
consequence of the disease is the degeneration of ganglionic cells in the myentric plexus of the
esophageal body and LES. Although the cause of the degenerative process is unclear, the end result of
the inflammatory process is loss of inhibitory neurotransmitters, nitrous oxides and vasoactive
intestinal peptides and, consequently, the imbalance between the excitatory and inhibitory neurons. The
result is unopposed cholinergic activity that leads to incomplete relaxation of LES and reduced
peristalsis due to loss of gradient along the esophageal body.

Therapeutic recommendations for achalasia are largely surgical and include either graded pneumatic
dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication as initial therapy in those
who are fit and willing to undergo surgery.[5] However, PD and surgical myotomy are recommended to
be performed at high-volume centers of excellence only. The choice of initial therapy is to be guided by
patient's age, gender, preference and local institutional expertise.

Botulinum toxin therapy is also recommended in patients who are not good candidates for more
definitive therapy with PD or surgical myotomy. Pharmacologic therapy for achalasia is recommended
for patients who are unwilling or cannot undergo definitive treatment with either PD or surgical
myotomy and have failed botulinum toxin therapy. These therapeutic options available for achalasia are
neither available nor affordable to the majority of people in India. In such a nebulous condition,
looking for a feasible yet effective Ayurvedic intervention for achalasia could be a fruitful exercise.

A delayed peristalsis resulting in delayed emptying of the esophagus is understood as a vata

abnormality in Ayurveda. Deglutition, movement of the food in the intestine and defecation are
considered to be a function of vata. Any abnormality in these functions therefore is supposed to be
originating because of a derangement in vata. A spasm and subsequently derived pain is also
considered an outcome of vata derangement in Ayurveda. Ayurveda does not describe any specific
disease entity resembling that of achalasia, but essentially the symptom complex is that it can easily be
inferred in terms of Ayurveda.

CASE REPORT
An otherwise healthy female of about 52 years developed, gradually, a regurgitation of food after meal
in the beginning of the year 2012. This was subsequently associated with dysphagia and occasional
heart burn. She was treated by a family physician initially with the help of H2-blockers and Imidazole
drugs (23-April-2012). A transient relief occurred with subsequent relapse of the symptoms. Gradually,
the patient developed the features of dysphagia with solid as well as with liquid foods. She was
subsequently treated with antacids, antiemetic and neurotropic vitamins (21-September2012).
Following no relief with the given treatment, she visited an ENT specialist. This time, she was
diagnosed as having reflux esophagistis and was given prokinetics, antiemetics, multivitamins and a
tranquilizer in addition to the H2-blockers (12-October-2012). During the course of this illness, the
patient was variously investigated to rule out certain conditions in a bid to diagnose her case. These
investigations included chest radiograph and various hematological investigations, including complete
blood counts and liver function test, which were all normal eventually. She was found to be non-
diabetic and non-hypertensive. An ultrasonography of the abdomen was also of no specific finding. Her
thyroid functions were also found to be within the normal range.

With progressive complaints of vomiting following the intake of food, retrosternal burning and
dysphagia, she further consulted at a secondary care hospital in Lucknow (21-May-2013). This time,
the patient had gone for upper gastrointestinal endoscopy, which revealed a mild antral gastritis without
any other significant finding (3-March-2013). She was then recommended for PPIs, prokinetics and
antiemetic along with a hepatic stimulant. There was symptomatic relief, but the symptoms recurred
after a few days.

Perplexed with the sustained symptoms, recurring repeatedly and with a confusion about the possible
cause of the disease, this time the patient consulted an ayurvedic teaching hospital in Lucknow (SR,
PC) for an Ayurvedic opinion in her case (05-April-2014).

Upon interrogation in the Ayurvedic clinic, the patient reported to have recurrent vomiting every
afternoon 2–3 h after food intake, retrosternal burning, food-related dysphagia and an apprehension
with food intake because of fear of vomiting and pain. Upon pulse examination, the patient was found
to have an excess of pitta. (This method of pulse examination was empirically developed by the
authors for a rapid clinical diagnosis of dominant dosha at the time of clinical examination. It was
hypothesized that the clinical features at a given time should correspond to the dosha prevalence and
hence it can help making the management plans. A validation study of pulse examination techniques is
under progress.) Her prakriti was suggestive of vata dominance (this prakriti examination was
performed by the authors on the basis of their clinical experience and scientific studies performed to
standardize the methods of prakriti examination in the clinic).[6] Upon Ayurvedic analysis, her
symptoms were proposed to be attributed to vata and pitta derangement, causing poor esophageal
motility and LES spasm, leading to the retention of food in the esophagus terminating into dysphagia
finally (spasm and obstruction are considered to be the symptoms caused by vata). A retrosternal
burning could have been attributed to excess of dushta pitta (urdhvagaamla pitta symptoms are akin to
that of retrosternal burning). A manometry would have been the ideal method to diagnose this case for
its possibility of having achalasia, but this was not done because of its unavailability. With a
hypothesized Ayurvedic pathology in this case, the patient was advised for barium swallow
examination, which has shown a moderate dilation of esophagus and partial narrowing of the lower
esophageal sphincter (9-April-2014) (image not available). Taking cues from the barium swallow,
which has empirically supported the Ayurvedic pathological hypothesis in the case (LES narrowing is
proposed to be caused by excess vata), the treatment plan was made aiming at removing the esophageal
impediment by vata regulation by Ayurvedic drugs and internal snehana aiming at improved
esophageal motility-reduced LES spasm. The excess of pitta causing retrosternal burning was taken
care of with the help of a few pitta-reducing drugs. The following Ayurvedic treatment was
recommended to the patient [Table 1].
 Table 1
Ayurvedic management of achalasia patient

Open in a separate window

The Ayurvedic treatment was continued for about 3 months. A significant symptomatic improvement
was observed in the patient after 1 month of the initial Ayurvedic therapy. There had not been any
regurgitation of food and there was minimal dysphagia associated with either kind of food intake.
There had remained an occasional retrosternal burning, but to a minimal extent compared with its
earlier intensity. She gained 2 kg since she came under Ayurvedic therapy (50 kg before treatment and
52 kg after 3 months of treatment). The patient was called for follow-up every month with a
continuation of Ayurvedic treatment. No specific complaints were reported in the last 2 months of
follow-up.

DISCUSSION
Achalasia is an uncommon disorder of the esophagus that results in symptoms like regurgitation of
food, dysphagia and retrosternal burning. The treatment options in this condition are not very clear and
often require a combination of invasive surgical procedures requiring a center of excellence to perform.
This condition also poses a diagnostic dilemma, causing a misdiagnosis of GERD in many cases.[11]
In the absence of defined and easily executable therapy, the patients often live a miserable life where
their food-related activities are thoroughly compromised. Because of the apprehension of regurgitation,
dysphagia and chest pain related with food intake, the patients often limit their food intake to a
minimum just to minimize the chances of recurrence of food-related symptoms. The present case gives
us an opportunity to look into the pragmatic ease and effectiveness of Ayurvedic therapeutics in an
entirely new dimension. This is an example of how the missed diagnosis can change the course of the
management only to delay the responses (an early diagnosis and subsequent treatment might have
changed the course of the disease in this case). It also explores that, sometimes, the evidence-based
recommendations in allopathic medicine are not possible to be executed in India either because of the
lack of expertise they require or the cost involved therein. This also explains how the modern
investigations can not only be inferred well in terms of Ayurveda, but can also be qualitatively utilized
to improve the Ayurvedic clinical practice. This case also presents us an example as to how a simple
Ayurvedic approach of diagnosis and management can save time and resources by offering relief in a
given clinical condition compared with the cumbersome and cost-intensive interventions proposed by
allopathic medicine.

Achalasia is an uncommon clinical condition that is commonly misdiagnosed as GERD in the family
practice.[7] A non-responding patient on conventional therapy with a suspected diagnosis of GERD
often puts the treating physician into a flux, and it often results in the addition of anxiolytics and
tranquilizers in the treatment prescriptions (as it happened in the present case).

A recurrent regurgitation of food after 2–3 h of a meal is a clear indicator of reduced esophageal
peristalsis and increased tone of the lower esophageal sphincter.[8,9] A dysphagia associated with solid
and liquid food in the absence of any endoscopic finding is suggestive of a pathology that is more
functional rather than being organic in nature. This case was treated through Ayurveda in a novel way.
The novelty of this approach was to consider the basic doshas responsible for the symptom, their
confirmation with the help of modern diagnostic tools and planning a treatment aiming at specific
dosha causing the symptoms. This method of treating a disease is called as dosha pratyaneekchikitsa in
Ayurveda. The primary treatment offered to the patient was Hingvadibati composed of asafetida root
resin extract, which is an Ayurvedic prokinetic (vatanulomak), thereby increasing the eosophageal
peristalsis.[10] Erandataila (castor oil) was selected as a special anupana (vehicle) with this drug to
enhance the vatanulomana property of the drug and at the same lubricating the LES to release its
spasm. Avipattikarachurna, another preparation used in the treatment, was mainly composed of nishoth
(operculinaturpethum), which is a known purgative. This preparation was supposed to increase the
peristalsis again along with a care for increased pitta causing a retrosternal burning. The other
preparations like shankhabati and pravalbhasma were mainly intended to reduce the pitta to counter
the retrosternal burning. It was the combined effect of all these preparations that has resulted in a clear
and stable clinical improvement in the patient. A gain in weight within this period of Ayurvedic
treatment was a clear testimonial of the patient's better tolerance with food and reduced intensity of the
symptoms.

CONCLUSION
For majority of achalasia cases in India belonging to common rural and suburban settings, the kind of
recommendations made by the ACG are neither affordable nor executable. Ayurveda proposes to offer
a dependable remedy in such cases where the clinical symptoms are suggestive of achalasia and where
the conventional allopathic therapy is not offering any sustainable benefit. Taking these leads further,
this can also offer a dependable cure for such cases if more intensive clinical trials can be performed
with similar cases to further prove its efficacy.

Footnotes
Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES
1. Vaezi MF, Richter JE. Diagnosis and management of achalasia. American college of
gastroenterology practice parameter committee. Am J Gastroenterol. 1999;94:3406–12. [PubMed]

2. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: Diagnosis and management of achalasia.
Am J Gastroenterol. 2013;108:1238–50. [PubMed]

3. Holloway RH. Esophageal manometry. GI Motility Online 2006. doi: 10.1038/gimo30 Published 16
May 2006.

4. Francis DL, Katzka DA. Achalasia: Update on the disease and its treatment. Gastroenterology.
2010;139:369–74. [PubMed]

5. Guidelines for the surgical treatment of esophageal acahalsia. [Last accessed on 2014 Aug 02].
Availablefrom http://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-
esophageal-achalasia .

6. Rastogi S. Development and validation of a prototype prakriti analysis tool (PPAT): Inferences from
a pilot study. Ayu. 2012;33:209–18. [PMC free article] [PubMed]

7. PrakashGyawali C. Esophageal hypersensitivity. In: Richter JE, editor. Advances in

GERD.Gastroenterol and Hepatol. Vol. 6. New York: 2010. pp. 497–500.

8. Roman S, Kahrilas PJ. Management of spastic disorders of the esophagus. GastroenterolClin North
Am. 2013;42:27–43. [PMC free article] [PubMed]

9. Chuah SK, Hsu PI, Wu KL, Wu DC, Tai WC, Changchien CS. 2011 update on esophageal achalasia.
World J Gastroenterol. 2012;18:1573–8. [PMC free article] [PubMed]
10. Rastogi S, Rastogi R. Psychotherapeutic approach to functional dyspepsia: A case report.
Gastroenterology Today. 2003;7:45–6.

11. McCormick SE, Kozarek RA. Endoscopic evaluation of esophageal motility disorders. GI Motility
Online. 2006. [Last accessed on 2014 Nov 07]. doi: 10.1038/gimo29 Published 16 May 2006
http://www.nature.com/gimo/contents/pt1/full/gimo29.html .

Articles from Journal of Ayurveda and Integrative Medicine are provided here courtesy of Elsevier