Achalasia

Question 1

Define Achalasia

Answer 1

Achalasia is an oesophageal motor disorder characterised by oesophageal aperistalsis and insufficient LOS relaxation in response to swallowing.

Question 2

Explain the aetiology/risk factors for Achalasia?

Answer 2

• Normally when swallowing, inhibtory neurons release NO to cause the LOS to relax and allow passaeg of food into Stomach
• Inflammatory destruction of inhibitory nitrinergic (NO) neurons in the oesophageal myenteric (Auerbach) plexus results in loss of peristalsis and incomplete lower oesophageal sphincter relaxation.

Risk factors include:

• Allgrove syndrome (achalasia, adrenal insufficiency & alacrima)
• Other Autoimmune diseases

Question 3

Recognise the presenting symptoms of achalasia

Answer 3

• Dysphagia to solids and liquids
• Feeling of food getting stuck
• Posturing to aid swallowing (arching neck, raising arms to increase intra-thoracic pressure)
• Recurrent chest infections due to aspiration
• Eating slowly
• Regurigitation ± Coughing when supine/recumbent (without sour taste)
• Chest pain/pressure

Question 4

Recognise the signs of achalasia on physical examination

Answer 4

• No specific signs
• Rapid weight loss may allude to pseudoachalasia (malignant stricture)

Question 5

Identify appropriate investigations for achalasia and interpret the results

Answer 5

• Barium swallow with X-ray (1st line): dilated oesophagus with beak-like narrowing at GOJ
• High-res oesophageal manometry: Incomplete relaxation of LOS (high LOS pressure) & aperistalsis in mid oesophagus
• Upper GI endoscopy (OGD): mainly to exclude malignancy, may also shoe retention of saliva

Question 6

Management

Answer 6

• 1st line: pneumatic dilation (balloon dilation)
• Surgical: Heller cardiomyotomy (cutting the muscle in LOS and gastric cardia)
• Botulinum toxin injection (patients who are not suitable for surgery owing to frailty or extensive comorbidities.)