achalasia

Question 1

define

Answer 1

Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated.

Achalasia typically presents in middle-age and is equally common in men and women.

Question 2

Clinical features

Answer 2

• dysphagia of BOTH liquids and solids
• typically variation in severity of symptoms
• heartburn
• regurgitation of food - may lead to cough, aspiration pneumonia etc
• malignant change in small number of patients

Question 3

Investigations

Answer 3

• manometry: excessive LOS tone which doesn’t relax on swallowing - considered most important diagnostic test
• barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
• CXR: wide mediastinum, fluid level

Question 4

Treatment

Answer 4

1. intra-sphincteric injection of botulinum toxin
2. Heller cardiomyotomy
3. balloon dilation
4. drug therapy has a role but is limited by side-effects