Benign Esophageal Disease Flashcards
Pathophysiology of achalasia
Achalasia results from damage to the myenteric plexus with selective destruction of inhibitory neurons in the myenteric plexus by cytotoxic T lymphocytes.
Mesenteric nervous system effects in achalasia
inflammatory neurodegenerative insult:
causes an imbalance between excitatory and inhibitory neurons,
cumulating in aperistalsis of the esophageal body and failure of LES relaxation.
sine Quo non of achalasia
- aperistalsis of the esophageal body
- failure of LES relaxation
Typical first diagnostic tests for Achalasia
- Barium esophagram
- esophagoscopy
(usually the first diagnostic tests performed because the usual symptoms are dysphagia and regurgitation. )
Achalasia:
Classic findings on Esophogram?
Classic findings on esophagram:
esophageal dilation
aperistalsis
impaired esophageal emptying symmetrical tapering at the EGJ (bird’s beak or ace of spades appearance)
Esophagoscopy findings of Achalasia.
Esophagoscopy:
- usually shows some degree of food or fluid retention (occasionally only saliva)
- chronic stasis changes, and a tight, spastic or puckered EGJ,
- not restricting endoscope passage.
Role of EGD in the diagnosis of achalasia
When achalasia is suspected:
endoscopy is essential to exclude benign or malignant strictures, particularly pseudoachalasia (esophageal obstruction secondary to malignancy), which may be clinically and manometrically indistinguishable from primary achalasia.
Manometric findings of achalasia
Manometrically, achalasia is defined:
incomplete or failed relaxation of the LES and aperistalsis of the esophageal body
LES manometry
Resting LES pressure can be normal in up to 50% of patients;
elevated LES pressure is not required for diagnosis
How many types of achalsia on manometry
Three
Type 1 Achalasia
Type I (classic):
has minimal or no esophageal pressurization or peristaltic activity
Type II achalasia
Type II:
panesophageal pressurization, greater than 30 mm Hg, throughout the entire esophagus in at least 20% of sequences;
Type III Achalasia
type III (spastic, vigorous):
is associated with 20% or more swallows associated with premature contractions.
Prognosis for type II achalasia:
Type II achalasia has been reported to be a predictor of an excellent outcome after all available treatment modalities.
Type I Achalasia prognosis
Type I patients do significantly better with Heller myotomy than with pneumatic dilation.
What type of achalasia have the worst prognosis
Type III and pretreatment esophageal dilation were predictive of poorer outcomes.
Two most effective treatment modalities for achalasia?
- Pneumatic dilation
- surgical myotomy
Pneumatic dilation achalasia:
method and effectiveness.
-
Rigiflex balloon dilator
- (balloon diameters of 3.0, 3.5, and 4.0 cm)
- successful in controlling symptoms in 50% to 93% of patients.
- Graded dilator
- 3.0 cm, 3.5 cm, and 4.0 cm
- results in good-to-excellent response rates of 74%, 86%, and 90%,
Perforation rate with the rigiflex balloon dialation:
Rigiflex balloon dilation:
reported a 2.0% perforation rate
Rigifix balloon dilation of achasia:
% Good results at follow up ?
Recurance rate ?
- 78% good or excellent results at 3-year follow-up.
- >1/3 of patients will have symptom recurrence during a 4-year period,but they may respond to repeat dilation.
Achlasia: long term outcomes
After 4.8 years of follow-up, laparotomy and myotomy provided symptom control in 95% of patients, whereas pneumatic dilation with the Mosher system provided symptom control in 65%.
