Achalasia

Question 1

Define achalasia

Answer 1

Condition where normal muscular activity of oesophagus is disturbed (absent or uncoordinated) due to failure of incomplete relaxation of lower oesophageal sphincter
Delay in passage of swallowed material into stomach

Question 2

Explain the aetiology / risk factors of achalasia

Answer 2

Degeneration of ganglion cells of the myenteric plexus in oesophagus
Unknown cause
Infection with Trypanosoma cruzi- Chagas disease- has similar disorder

Question 3

Summarise the epidemiology of achalasia

Answer 3

Affects all ages
Affects sexes equally
1 in 100,000

Question 4

Recognise the presenting symptoms of achalasia

Answer 4

Insidious onset and gradual progression of:
Intermittent dysphagia involving solids and liquids
Difficulty belching
Regurgitation (particularly at night)
Heartburn
Chest pain (atypical/cramping, retrosternal)
Weight loss (because they are eating less)

Question 5

Recognise the signs of achalasia on physical examination

Answer 5

Aspiration pneumonia
Malnutrition
Weight loss

Question 6

Identify appropriate investigations for achalasia and interpret the results

Answer 6

CXR may show:
Widened mediastinum
Double right heart border (dilated oesophagus)
Air-fluid level in the upper chest
Absence of the normal gastric air bubble

Barium swallow may show:
Dilated oesophagus which smoothly tapers down to the sphincter (beak-shaped)

Endoscopy to exclude malignancy (which could mimic achalasia)

Manometry (used to assess pressure at the LOS) may show:
Elevated resting LOS pressure (> 45 mm Hg)
Incomplete LOS relaxation
Absence of peristalsis in the smooth muscle portion of the oesophagus
NOTE: you may do serology for antibodies against T. cruzi if CHAGAS DISEASE is a possibility (and blood film may detect parasites)