Achalasia

Question 1

Definition

Answer 1

Oesophageal motility disorder characterised by an inability for the lower oesophageal sphincter to relax in response to swallowing
- rare and idiopathic

Question 2

Risk factors

Answer 2

Genetic: Allgrove syndrome (rare autosomal recessive)
Infection
Autoimmune diseases

Question 3

Signs

Answer 3

Cachectic (loss of body weight and muscle mass)
Aspiration pneumonia

Question 4

Symptoms

Answer 4

Dysphagia of both solids and liquids
Regurgitation: may lead to coughing
Retrosternal chest pain: heart burn
Coughing when lying down
Weight loss due to reduced oral intake

Question 5

Diagnosis

Answer 5

FIRST LINE: Upper GI endoscopy (OGD): low sensitivity but first line in order to exclude malignancy
GOLD STANDARD: High-resolution oesophageal manometry
- incomplete relaxation of LOS
- oesophageal aperistalsis
Barium swallow
- “bird beak”

Question 6

Management

Answer 6

FIRST LINE = medical: CCB (verapamil) and nitrates (isosorbide dinitrate) = reduce pressure and relax the LES. Usually ineffective and used whilst awaiting definitive treatment
GOLD STANDARD: ONLY SURGERY CURATIVE
- Balloon stenting

Question 7

Complications

Answer 7

• May increase risk of oesophageal squamous cell lung cancer
• Aspiration pneumonia: due to regurgitation, particularly nocturnal aspiration
• GORD
• Perforation