Achalasia

Question 1

summarise achalasia?

Answer 1

intermittent dysphagia to both liquids and solids

regurgitation and retrosternal chest pain

halitosis

Question 2

define achalasia?

Answer 2

condition in which normal muscular activity of the oesophagus is disturbed ( Absent or uncoordinated) due to failure or incomplete relaxation of lower oesophageal spincter

Question 3

outline the aetiology of achalasia?

Answer 3

it is caused by inflammatory degeneration of the ganglion cells of the myenteric plexus in the oesophagus due to an unknown cause

More likely to suffer from AI conditions

NOTE: oesophageal infection with Trypanosoma cruzi seen in Central/South America produces a similar disorder (CHAGAS DISEASE) – also causes myocarditis + achalasia

Question 4

summarise the epidemiology of achalasia?

Answer 4

It may occur at any age (mainly 25-60 yrs)

Affects both sexes equally

Annual incidence 1/100,000

Question 5

outline the presenting symptoms of achalasia

Answer 5

INSIDIOUS onset and gradual progression of:

• Intermittent dysphagia involving solids and liquids (liquids when very advanced)
• May cause them to sit up straight/stand up during meals and walk around after meals/ arching neck and shoulders/ raising arms

Eat slower

Difficulty belching

Regurgitation (particularly at night)

Heartburn

Chest pain (atypical/cramping, retrosternal)

Weight loss (because they are eating less)

Coughing when lying down

Globus sensation and so down lots and lots of water

Question 6

what are the signs of achalasia on physical examination?

Answer 6

May show signs of complications:

Aspiration pneumonia (recurrent chest infections)

Malnutrition

Weight loss

Question 7

What are the appropriate investigations

Answer 7

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

Question 8

What investigations should you consider for achalasia?

Answer 8

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

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