Achalasia Flashcards
What is the purpose of the oesophagus?
Connects the pharynx (level of C6) to the stomach (level of T11)
Where is the oesophagus located?
Between trachea and spine
Through which hiatus does it cross the diaphragm and which level?
Oesophageal hiatus at the level of T10
Which part is extraperitoneal and which is intraperitoneal?
Thoracic oesophagus is extraperitoneal
Abdominal oesophagus is intraperitoneal
What are the 4 oesophageal constrictions?
Cricopharyngeal sphincter at C6
Crossing of aortic arch at T4/5
Crossing of left main bronhchus at T5/6
Crossing of diaphragm at T10
What is the function of the oesophagus?
Passage of food and liquids between oropharynx and stomach
What is the cervical vasculature the of the oesophagus?
Oesophageal branches of inferior thyroid artery and inferior thyroid vein
What is the thoracic vasculature the of the oesophagus?
Oesophageal branch’s if the thoracic aorta
Azygos and heniazygos veins
What is the abdominal vasculature the of the oesophagus?
Oesophageal branches of the left gastric arteries
Left gastric vein (which drains into the portal circulation)
Which lymphatic system drains the oesophagus?
Mediastinal lymph nodes
Which nerves innervate the oesophagus?
Sensation - vagus nerve
Sympathetic - cervical and thoracic trunk (decrease peristalsis and glandular activity and transmit pain)
Parasympathetic - striated muscle - vagus nerve.
Smooth muscle - parasympathetic fibres of vagus nerve
What are the 4 layers of the oesophagus?
Mucosal (innermost) - non keratinising stratified squamous epithelium. Transitions to columnar epithelium at GE junction.
Submucosal -contains blood vessels, glandular epithelium and meissner’s plexus
Muscular -contains inner circular and outer longitudinal muscle fibres. Auerbach’s plexus lies between the 2.
Adventitia (outermost)
What is the definition of achalasia?
Oesophageal motility disorder characterised by inadequate relaxation of LES and non peristaltic contractions in distal 2/3 of oesophagus due to degeneration of inhibitory neurons.
Which age group does Achalasia mostly occur in?
Middle aged individuals
What is the cause of primary and secondary achalasia?
Primary - unknown
Secondary - mechanical cause of obstruction eg malignancy that mimics achalasia (eg oesophageal cancer, amyloidosis, sarcoidosis)
What is the pathophysiology behind achalasia?
Swallowing controlled by excitatory neurohormonal substances. Atrophy if inhibitory neurons in auerbach’s plexus leads to lack of inhibitor neurotransmittors -> inability to relax LES and increased resting pressure and dysfunctional peristalsis. -> oesophageal dilation proximal to LES.
What are the 4 clinical features of achalasia?
Dysphasia
Regurgitation
Retrosternal pain and cramps
Weight loss
Which diagnostic tests should be done to confirm achalasia?
Initial - upper endoscopy and barium swallow.
Oesophageal manometry to establish diagnosis.
If manometry not conclusive, do. Oesophagram to confirm.
Endoscopy done to rule out pseudo achalasia.
What 2 signs do you look out for in oesophageal barium swallow for achalasia?
Bird beak sign - dilation of proximal oesophagus with stenosis of the GE junction
Delayed barium emptying or barium retention
What is the purpose of a lab upper endoscopy for achalasia? And what else will it show?
Rule out pseudoachalasia
Usually normal. May show retained good in oesophagus. If malignancy suspected, biopsy and endoscopic ultrasound
What will an oesophageal manometry show for achalasia?
Peristalsis is absent or uncoordinated in lower 2/3 of oesophagus.
Incomplete or absent LES relaxation
High LES resting pressure
No evidence of mechanical obstruction
What will a chest X-ray show for achalasia?
Widened mediastinum
Air fluid level on lateral view
Possible absence of gastric air bubble
What is the differential diagnosis for achalasia?
Oesophageal cancer
Schatzki ring
Oesophageal stricture
Chagas disease
Extrinsic compression
Scleroderma
What are the treatment options for achalasia?
If low surgical risk
Pneumatic dilation surgery
LES myotomy
Peroral endoscopic myotomy
If high surgical risk
Botulinum toxin injection in LES
if failure, nitrates or calcium channel blockers
What does a pneumatic dilation surgery di?
Dilation of LES that tears the surrounding muscle fibres with the help of a balloon
What does a LES myotomy do?
Surgical procedure in which the LES is incised longitudinally to re-enable passage of food or liquids in stomach
What does a peroral endoscopic myotomy do?
Myotomy (cutting of muscular layer) of inner circular muscle layer of LES
What are the complications of achalasia?
Pulmonary complications. Eg pneumonia, abscess, asthma - caused by aspiration
Mega-oesophagus
Increased risk of oesophageal cancer
