Achalasia Totally Explained

Everything about Achalasia totally explained

Achalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, dyssynergia esophagus, and esophageal aperistalsis, is an esophageal motility disorder, a disease is which normal movement of the muscles in the esophagus is disturbed. It is characterized by difficulty swallowing, chest pain and Diagnosis is reached with esophageal manometry. Various treatments are available, but none cure the condition completely. Certain medications may be used, as well as injection of the esophageal muscles with botulinum toxin, but more permanent relief is brought by esophageal dilatation and surgical cleaving of the muscle (for example a procedure known as Heller myotomy).
In achalasia, the smooth muscle layer of the esophagus has impaired peristalsis (muscular ability to move food down the esophagus), and the lower esophageal sphincter (LES) fails to relax properly in response to swallowing. The most common form is primary achalasia, which has no known underlying cause. However, a small proportion occurs as a secondary result of other conditions, such as esophageal cancer or Chagas disease (an infectious disease common in South America). Achalasia affects one person in 100,000 every year.

Treatment

Medication:
- Intra-sphincteric injection of botulinum toxin (or botox), to paralyze the lower esophageal sphincter and prevent spasms. As in the case of botox injected for cosmetic reasons, the effect is only temporary, and symptoms return quickly in most patients. Botox injections cause scarring in the sphincter which may increase the difficulty of later Heller myotomy. This therapy is only recommended for elderly patients who can't risk surgery.
- Drugs that reduce LES pressure may be useful, especially as a way to buy time while waiting for surgical treatment. These include calcium channel blockers such as nifedipine, and nitrates such as isosorbide dinitrate and nitroglycerin. Unfortunately, many patients experience unpleasant side effects such as headache and swollen feet, and these drugs often stop helping after several months.

Balloon (pneumatic) dilation, also called dilatation. The muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincter. Gastroenterologists who specialize in achalasia and have done many of these forceful balloon dilations have better results and fewer perforations than inexperienced ones. There is always a small risk of a perforation which would have to be fixed by surgery right away. Gastroesophageal reflux (GERD) occurs after pneumatic dilation in some patients. Pneumatic dilation causes some scarring which may increase the difficulty of Heller myotomy if this surgery is needed later. Pneumatic dilation is most effective on the long term in patients over the age of 40; the benefits tend to be shorter-lived in younger patients. This treatment may need to be repeated with larger balloons for maximum effectiveness.

Surgery: Heller myotomy helps 90% of achalasia patients. It can usually be performed by a keyhole approach, or laparoscopically. The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. A partial fundoplication or "wrap" is added in order to prevent excessive reflux, which can cause serious damage to the esophagus over time. In a Dor (anterior) fundoplication, part of the stomach is laid over the esophagus and stitched in place so whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.

Alternative treatments: Some patients have reported temporary improvement with acupuncture, traditional Chinese herbal medicine, or relaxation techniques.

Lifestyle changes: Achalasia patients need to eat slowly, chew very well, drink plenty of water with meals, and avoid eating near bedtime. It is helpful to sleep with the head elevated by raising the head of the bed or using a wedge pillow. Proton pump inhibitors may help prevent reflux damage after surgery by inhibiting gastric acid secretion. Foods that can aggravate reflux, including ketchup and other tomato products, citrus fruits, chocolate, mint, alcohol, and caffeine, should also be avoided.

Follow-up monitoring: Even after successful treatment of achalasia, swallowing may still deteriorate over time. It's important to check every year or two with a timed barium swallow because some may need pneumatic dilations, a repeat myotomy, or even esophagectomy after many years. Some doctors recommend pH testing and endoscopy to check for reflux damage, which may lead to a stricture or cancer of the esophagus if untreated.Further Information

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