Achalasia

• “results from damage to nerves in the oesophagus, preventing the oesophagus from squeezing food into the stomach”  
• Aetiology/Pathogenesis: Unknown cause. Loss of nerve cell ganglia from Myenteric Plexus. Progresses:  later may lose dorsal vagal nuclei within brainstem

• Features:
  • Failure of peristalsis
  • Failure of relaxation of LES
  • Increased LES resting tone

• Epidemiology:
  • 30-60 years
  • 1/100 000/year

• Clinically:
  • Dysphagia to SOLIDS AND LIQUIDS
    • May be worse for liquids than solids
    • Often drinking heaps of water gets food down
    • Chest pain (due to spasms)
    • Regurgitation (old food, undigested, especially AT NIGHT)
    • 

• Complications
  • Aspiration pneumonia
  • Oesophageal erosions, diverticula 
  • Oesophagitis:  Candida
  • Squamous Cell Carcinoma (5%)

• Investigations:
  • Barium Swallow:  “Rat’s tail” appearance (expanded or sigmoid shaped tube, tight/tapered distally)
  • CXR:  may reveal a dilated esophagus and absence of air in the stomach
  • Esophageal manometry
  • endoscopy – reveals a dilated esophagus that contains retained food; it may also reveal inflammation, small ulcers caused by residual food or pills, and candida infection

• Treatment:
  • Short-term:  nitrates, hydralazine (pain relief)
  • Long-term:
    • Endoscopic balloon dilatation (BUT: risk of perforation with procedure, chronic reflux)
    • Heller’s procedure:  Cardiomyotomy (BUT: chronic reflux)