Achalasia

Question 1

Define Achalasia, its aetiology and epidemiology.

Answer 1

Achalasia is an oesophageal motility disorder where there is a loss in peristalsis and inability to relax the lower oesophageal sphincter.

Aetiology- Ganglion cells in myenteric plexus degenerate in oesophagus. Infection with Trypanosome cruzi present similarly

Epidemiology- Can occur at any age (esp 25-60yrs), both sexes equally, has incidence of 1/100,000

Question 2

Describe the history/presenting symptoms of Achalasia

Answer 2

Insidious onset with progression of:

• Intermittent dysphagia involving solids
• Difficulty belching
• Regurgitation (esp at night)
• Heartburn
• Chest pain (atypical/cramping, retrosternal)
• Weight loss (because they are eating less)

Question 3

What are the signs of Achalasia upon physical examination?

Answer 3

Examination may reveal signs of complication that include:

• Aspiration Pneumonia
• Malnutrition
• Weight loss

Question 4

What investigations are used to identify Achalasia?

Answer 4

• CXR- Widened mediastinum, double right heart border (due dilated oesophagus), air-fluid level in upper chest, absence of normal gastric bubble
• Barium swallow- may show dilated oesophagus which smoothly tapers to sphincter
• Endoscopy- to exclude malignancy (which could mimic Achalasia)
• Manometry- Used to assess pressure at LOS?? which can show: elevated resting pressure (>45mmHg), incomplete LOS relaxation, absence of peristalsis in esophagus’ smooth muscle
• Serology- for T.cruzi antibodies to test for CHAGAS

Question 5

How is Achalasia managed?*

Answer 5

• Pneumatic balloon dilation of LOS
• Surgical myotomy via abdominal/thoracic approach
• Botulinum toxin injection
• Medical treatment (nitrates and calcium channel blockers)

Question 6

What are the complications of Achalasia?

Answer 6

If untreated:

• Aspiration pneumonia
• Malnutrition + weight loss
• Increased risk of oesophageal malignancy