Achalasia

Question 1

Define achalasia

Answer 1

Oesophageal aperistalsis and impaired relaxation of the lower oesophageal sphincter

Question 2

What are the causes/risk factors of achalasia?

Answer 2

• Unknown aetiology
• Inflammation of the ganglion cells of the myenteric plexus in the oesophagus e.g. infection (Chagas disease presents in a similar way), autoimmunity, genetics
• Allgrove syndrome - achalasia, alacrima and adrenal insufficiency

risk factors:
• Infection with herpes and measles viruses increase susceptibility to achalasia.
• AI conditions are more common if a patient has achalasia.
• Increased prevalence HLA class II antigens
• Consanguinity

Question 3

What are the symptoms of achalasia?

Answer 3

• Intermittent dysphagia (both solids and liquids)
• Difficulty belching
• Regurgitation (esp. at night)
• Heartburn
• Chest pain (oesophageal spasm)
• Weight loss

Question 4

What are the signs of achalasia?

Answer 4

• No specific signs on examination

Signs of the complications if present:
• Aspiration pneumonia
• Weight loss and malnutrition (e.g. anaemia)
• Oesophageal cancer

Question 5

What investigations are carried out for achalasia?

Answer 5

• CXR - Widened mediastinum and double right heart border due to oesophageal dilation.
- Air-fluid level in the upper chest
- Absence of normal gastric bubble
• Barium Swallow - Dilated oesophagus, smoothly tapers down to the sphincter (beak-shaped)
- Loss of peristalsis
- Delayed oesophageal emptying
• Endoscopy - To exclude malignancy or obstruction.
• Oesophageal Manometry - Incomplete LOS relaxation
- High LOS pressure (>45 mmHg)
- Absence of peristalsis distally
• Serology - Antibodies against Trypanosoma cruzi if Chagas’ disease is suspected based on epidemiology.
• Blood Film - Detect parasitic infection: Trypanosoma cruzi if Chagas’ disease is suspected based on epidemiology