Achalasia

Question 1

Pathophysiology?

Answer 1

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

Question 2

When does it typically present?

Answer 2

Middle-age

Question 3

Symptoms?

Answer 3

• dysphagia of BOTH liquids and solids
• typically variation in severity of symptoms
• heartburn
• regurgitation of food
o may lead to cough, aspiration pneumonia etc

Question 4

Can this turn malignant?

Answer 4

There can be a malignant change in small number of patients

Question 5

Investigations?

Answer 5

• oesophageal manometry
• barium swallow
• chest x-ray

Question 6

What is the most important diagnostic test?

Answer 6

Oesophageal manometry which will show excessive LOS tone which doesn’t relax on swallowing

Question 7

What will a barium swallow show?

Answer 7

It shows grossly expanded oesophagus, fluid level and a ‘bird’s beak’ appearance

Question 8

What may be seen on a chest x-ray?

Answer 8

A wide mediastinum and fluid level

Question 9

First-line treatment?

Answer 9

Pneumatic (balloon) dilation

Question 10

Treatment for recurrent or persistent symptoms?

Answer 10

Surgical intervention with a Heller cardiomyotomy

Question 11

What other drugs may be used?

Answer 11

• Botulinum toxin
• Nitrates
• Calcium channel blockers