Gastrointestinal

Question 1

Achalasia management Pharmacological

Answer 1

Nitrates, Ca channel blockers, PDE-5i to reduce sphincter pressure. These treatments have side effects (hypotension, pedal oedema, headache, rapid tolerance) that limit them to use for patients who decline or are waiting for more defintive action (pneumatic dilatation or surgery)

Question 2

Achalasia Mx non surgical

Answer 2

• Endoscopic injection of botulinum toxin: Used in poor candidates for surgery or those who relapse after myotomy, or as bridge therapy. Lasts only 6-12m, is expensive and may reduce success rate of myotomy
  Pneumatic dilatation: Improvement in 50-90% of patients but 30% recurr in 5y. Symptom relief similar to myotomy if available on demand.

Question 3

Achalasia Mx surgical

Answer 3

Laparoscopic Heller myotomy with partial fundoplication (which is an anti-reflux procedure) is first choice as the myotomy can cause unopposed reflux. Insicion into fibres of LOS leading to relaxation. Success 76-100%

Question 4

Complications of achalasia

Answer 4

1. Perforation- Consider Mx with NBM, broad spec Abx and PPI with nutritional support. But may require surgical intervention to close perforation
   
   2. Recurrence - step up treatment ladder if not already done
   3. GORD - PPI, use of fundoplication with surgical approach
   4. Bloating
      Cancer risk increased (oesophageal)

Question 5

Achalasia prognosis

Answer 5

Most patients who are treated have normal life expectancy
Disease does recurr and patients may need intermittent Mx
Slight increase risk of cancer