Achalasia


Overview

Achalasia is an uncommon condition. Due to this, food and drinks cannot pass into the mouth and stomach. The muscular tube (esophagus) carries food from the mouth to the stomach. The lower esophageal sphincter is a ring-shaped muscle located where the esophagus and stomach converge (LES). While allowing food to enter the stomach, this muscle relaxes (opens) and contracts (tightens to seal) to stop stomach contents from backing up into an esophagus. The LES doesn't relax if you have achalasia, which stops food from entering the stomach.

Achalasia can result in significant loss of weight and malnutrition. Additionally, those with achalasia are slightly more likely to acquire esophageal cancer, especially if the illness has been present for a long time. Based on manometric patterns, achalasia is a heterogeneous disease that can be divided into three distinct types: type I (classic), which has minimal esophageal body contractility; type II, which has sporadic panesophageal pressurization; and type III (spastic), which has premature or spastic distal esophageal contractions. Early achalasia (esophageal diameter 4 cm), moderate achalasia (esophageal diameter 4-6 cm), and severe achalasia (esophageal diameter >6 cm) are present with their symptom patterns. This condition has been radiographically classified into sub-stages.

Causes

It is an unknown cause of esophageal muscles cannot contract and relax usually. According to one idea, achalasia is an autoimmune disorder in which the body attacks itself and is brought on by a virus. The nerve cells in the muscle layers of your esophageal walls and at the LES are attacked by your immune system. The muscle-controlling nerve cells slowly deteriorate for causes that are yet unknown. This causes the LES to contract too much. Achalasia prevents food and liquids from passing through the esophagus and into the stomach by preventing the LES from relaxing. Achalasia, an uncommon condition, may run in families.

Symptoms

The signs of achalasia appear gradually and may persist for months or years. Symptoms are reported as follows 

Issues with swallowing (dysphagia). The most prevalent initial symptom is this one.

Vomiting up partially digested meals.

Intermittent, sometimes excruciating chest pain.

Heartburn.

A nighttime cough

Malnutrition and weight loss as a result of eating problems. It is an advanced sign.

Cramps, trouble belching (less common symptoms)

Diagnosis

Three procedures are frequently used to identify achalasia −

  • Barium Swallow − For this test, ingest a liquid or other form of the barium preparation, and X-rays are used to assess the movement through the esophagus. The barium swallow has to demonstrate oesophageal narrowing at the LES.

  • Upper Endoscopy − During this examination, an endoscope, a flexible, thin tube with a camera, is passed down to the esophagus. The esophagus' 's inside is captured by the camera and displayed on a screen for analysis. This examination evaluates for achalasia and helps rule out carcinogenic (malignant) tumors.

  • Manometry − This examination evaluates the timing, force, and relaxation of the lower esophageal sphincter and the esophageal muscle (LES). The LES confirms that achalasia fails to relax after swallowing and the absence of muscular spasms along the esophageal walls. The "gold standard" test for achalasia diagnosis is this one. Some achalasia issues are caused by food gurgling (backing up) into the esophagus and then being dragged into (aspirated) the trachea, which connects to the lungs.

These Complications Include

Pneumonia.

Lung ailments (pulmonary infections).

Esophageal cancer is one of the additional complications. Your risk of developing this

malignancy rises if you have achalasia.

Treatment

  • Both nonsurgical (such as balloon dilation, drugs, and botulinum toxin injections) and surgical techniques are available for treating achalasia. The lower esophageal sphincter is relaxed as part of the treatment to alleviate the disease symptoms (LES).

  • The doctor selects these alternatives with the progression of the disease so that both may choose the best course of action based on the severity of the ailment and personal preferences.

Minimally Invasive Surgery

  • Laparoscopic esophagostomy, also known as laparoscopic Heller myotomy, is the surgical procedure used to treat achalasia. An endoscope, a thin, telescopic-like tool, is introduced through a tiny incision during this minimally invasive procedure. An endoscope is attached to a little, dime-sized video camera that beams an image of the surgical site onto operating room television monitors. The LES's muscle fibers are severed during this procedure. As a supplement to the Heller myotomy operation, partial fundoplication aid in preventing gastroesophageal reflux, a side effect.

  • Laparoscopic Heller myotomy can be replaced with a minimally invasive peroral endoscopic myotomy (POEM). During this treatment, a knife is used to sever the esophageal side muscles, LES, and upper stomach muscles. These cuts release the muscles in these locations, enabling the esophagus to empty as it should and send food into your stomach.

Balloon Dilation

  • During this nonsurgical technique, a specially made balloon will be placed via the LES and then inflated while given a mild sedative. The muscle sphincter relaxes as a result of the treatment, allowing food to pass into the stomach. In patients with unsuccessful surgery, balloon dilation is typically the primary course of action.

  • To keep the symptoms under control, you should have a few dilation treatments.

Medication

  • Botox® (botulinum toxin) injections may be helpful if balloon dilation or surgery is not an option or if you decide not to have either of these operations. The bacteria that cause botulism produce the protein known as botox. Botox can relax spastic muscles when injected into them in extremely modest doses. It functions by obstructing the nerve signal that instructs the sphincter muscles to constrict. Repeated injections are necessary to keep symptoms under control.

  • Nifedipine (Procardia XL®, Adalat CC®) and isosorbide (Imdur®, Monoket®) are two other drug therapies. By reducing LES pressure, these drugs ease the esophageal muscles' spasms. These therapies temporarily relieve your symptoms and are less effective than balloon dilation or surgery.

Esophagectomy

  • Esophagus removal is a last-resort procedure.

Updated on: 24-Jan-2023

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