Esophageal achalasia pathology, clinical features, investigations and treatment

Definition of Esophageal achalasia :

It is a motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter with aperistalsis in the body of the esophagus (atony).

Pathogenesis:
1) Degeneration in the myenteric nerve plexus of the esophageal wall.
2) Lesion in the nitric oxide containing neurons.

How to diagnose Esophageal achalasia ?

Clinical picture of Esophageal achalasia  :

(The disease is more common in middle-aged females).
- Intermittent dysphagia to fluids &to solid foods.
- Retrosternal chest pain occurs with vigorous non peristaltic contraction of the esophagus .
- Putrefaction of the retained food leads to halitosis.
- Chest infections may occur due to aspiration during sleep, due to regurgitation.
- Weight loss is usually not marked.

Investigations :

1. Chest x ray showing: Absence of gases in the fundus of the stomach.

2. Barium swallow shows Dilated esophagus, the lower end gradually narrows (bird's beak
deformity).
3. Upper endoscopy:
For diagnosis & to exclude cancer esophagus in achalasia the endoscope can pass easily through the narrowing without resistance.
4. Manometry: It shows aperistalsis with failure of the lower esophageal sphincter to relax.

How to manage a case of Esophageal achalasia ?

1. The treatment of choice is endoscopic dilatation.
2. Endoscopic botulinum toxin injection in the lower esophageal sphincter.
3. Laparoscopic cardiomyotomy if these measures fail (Heller's operation). i.e. division of the muscle at the lower end of the oesophagus, it can be done laparoscopically.
4. In old age Ca Ch blockers (Nifedipine) can be tried initially.

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