Achalasia

Question 1

Define achalasia

Answer 1

An oesophageal motor disorder characterised by a loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing.

achalasia is the greek word for ‘does not relax’

Question 2

Totally Summarise the symptoms and investigations for this condition;

Answer 2

The most common presenting symptoms are dysphagia (dificulty swallowing) to solids and liquids, regurgitation, and retrosternal pain.

These can be slowly progressive over months or years.

The first investigation for any patient with dysphagia is 1A. Endoscopy;
to exclude malignancy, but subsequent

1B. oct-21: apparently Manometry is 1st line now?

1C - Barium swallow studies and
-oesophageal manometry are usually required to establish the diagnosis of achalasia.

• Chest xray; wide mediastinum - bird beak appearance

Question 3

Recognise the presenting symptoms of achalasia

Answer 3

slowly progressive 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 4

Recognise the signs of achalasia on physical examination

Answer 4

May show signs of complications:

Aspiration pneumonia
Malnutrition
Weight loss

Lower likelihood;
GORD
Oesophageal cancer

Question 5

Identify appropriate investigations for achalasia

Answer 5

1st line tests;

1. Upper GI endoscopy
   mucosa with frothy appearance; in advanced cases oesophagus may be dilated and tortuous and contain food debris. also exclude malignancy.
2. Barium swallow
   - loss of peristalsis and delayed oesophageal
   emptying; dilated oesophagus that tapers smoothly to
   a beak-like narrowing at the gastro-oesophageal
   junction
3. Oesophageal manometry
   - checking the pressure inside.
   - high resting lower oesophageal pressure >45mmhg
   - Incomplete LOS relaxation

Question 6

Other investigations for achalasia?

Answer 6

Others
CXR may show:
Widened mediastinum
Double right heart border (dilated oesophagus)
Absence of the normal gastric air bubble

NOTE: you may do serology for antibodies against T. cruzi if CHAGAS DISEASE is a possibility (and blood film may detect parasites)

Question 7

Other differentials for dysphasia?

Answer 7

Oesophageal cancer
Oesophagitis
Oesophageal candidiasis - consider if taking steroids
Pharyngeal pouch
Myasthenia gravis