achalasia cardia | Master Of Medicine

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Achalasia Cardia

Megaesophagus

Megaesophagus (Photo credit: Wikipedia)

Failure of LES to relax. LES remains in a constant state of tone with periods of relaxation.

Etiology

Idiopathic
Infectious
Neurogenic degeneration
Stress
Trauma
Chagas disease

Pathophysiology

Young women, middle aged men and women are affected. Primary pathology is destruction of nerves to LES and failure to relax leading to esophageal dilation and loss of progressive peristalsis

Achalasia is a premalignant condition and in 20 year period chance of carcinoma is 8%.
SCC is the most common type of carcinoma seen in Achalasia.It is due to long standing air fluid levels, mucosal irritation leading to metaplasia. Adenocarcinoma affects middle 1/3 rd of esophagus.

Clinical features

Triad of dysphagia(begins with liquids and progress to solids), regurgitation and weightloss.

Complications
Pneumonia
Lung abscess
Bronchiectasis

Diagnosis

Barium esophagogram
Characterised by
1.Distal natrowing- Birds beak appearance
2.Absence of gastric air bubble
3.Later stages massive esophageal dilatation, tortuosity and sigmoidal esophagus(mega esophagus)

Motility study
Lack of peristaltic waves in the body of esophagus and failure of LES to relax.

Esophageal Manometry

Gold standard. Characterised by

1.LES hypertension- pressure more than 35mmHg
2.Failure of LES to relax with deglutition
3.Pressurisation of esophagus due to incomplete air evacuation
4.Simultaneous mirrored contractions with no evidence of progressive peristalsis
5.Low amplitude wave forms due to lack of muscle tone

Endoscopy
To evaluate mucosa for esophagitis or carxinoma.

Treatment
All treatment is aimed at relieving obstruction caused by LES contraction
Medical
1.In early stages sublingual nitroglycerine, nitrates or calcium channel blockers.
2.Bougie dilatation up to 54Fr
3.Botox injection to LES

Surgical

1.Surgical esophagomyotomy is superior to balloon dilatation
2.Modified laparoscopic Hellers myotomy is the operation of choice.It may be combined with an antireflux surgery like fundoplication
3.Esophagectomy is done in mega esophagus, sigmoid esophagus, failure of more than one myotomy,undilatable reflux stricture.

 

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