Achalasia

Achalasia


What is achalasia?

  • A dilated oesophagus
  • Absent peristalsis (contraction) of the oesophagus
  • Hypertensive lower oesophageal sphincter

What causes achalasia?

  • Idiopathic (autoimmune mediated destruction of inhibitory neurons in the oesophageal myenteric plexus)
  • Chagas disease

What is pseudoachalasia?

As the name lends itself to, is a process other than intrinsic disease of the oesophageal myenteric plexus leading to motor dysfunction identical to that of Achalasia. In other words it is a mechanical cause of a dilated oesophagus with absent peristalsis and increased tone of the lower oesophageal sphincter.

What can cause pseudoachalasia?

  • Tumours of the Gastric cardia
  • Gastro-oesophageal tumours

It is important that you see a specialist to rule out the difference between achalasia and pseudoachalasia. The management of the 2 conditions is very different.

What are the symptoms of achalasia?

  • Dysphagia (difficulty swallowing ) solids and liquids
  • Regurgitation of undigested food
  • Chest pain
  • Weight loss
  • Nocturnal cough
  • Heartburn (this is more commonly seen in gastro-oesophageal reflux disease)

How does acahalasia get diagnosed?

You will need to visit a specialist. Once you have had a complete history and examination done you will require a gastroscopy. In addition to this, radiology imaging in the form of either a barium swallow or CT scan with oral contrast. In addition to this (if achalasia is suspected) you will need to have an oesophageal manometry.

How do we classify achalasia ?

Type 1

  • Thought to represent a later presentation of type II with more extensive neural loss leading to minimal oesophageal body function with low pressure ≤30mmHg
  • There is often dilatation of the oesophageal body

Type 2

  • 50% of patients,
  • birds beak appearance on barium swallow usually with absent megaoesophagus
  • characterised by a pan-oesophageal pressure, with residual muscle function(circular & longitudinal) thought to correlate with less myenteric neuronal loss.
  • Best response to Cardiomyotomy

Type 3

  • least common
  • Typically spasm is in the distal third of the oesophagus with higher pressure and premature
  • preservation of myenteric neutrons but impaired inhibitory post-ganglionic neural function (functioning circular muscle with uncoordinated contractions- corkscrew appearance)
  • 50% response to cardiomyotomy

What options are there for treating achalasia?

Currently all treatment options are directed towards the management of symptoms only.
This can be:

  • Surgery (Laparoscopic Heller Myotomy)
  • Current gold standard for treatment of achalasia
  • Medication
  • Disadvantage: short acting, temporary relief, side effects of medication e.g. headaches
  • Endoscopic Botulinum toxin injections (inhibits the neurons in the oesophageal nerve plexus)
  • Disadvantage: Can result in transient improved symptoms
  • Endoscopic balloon dilatation
  • Disadvantage: Disruption of muscle fibres
  • Disadvantage: Requires a number of dilatations with each procedure carrying the risk of perforating the oesophagus

What is Laparoscopic Heller-Cardio Myotomy?

This is a ‘key hole’ operation that is done through the abdomen with the aim of mobilising the oesophagus up into the chest to create enough room to perform controlled division of the muscle fibres(myotomy) of the oesophagus that are constricting it. The intra-abdominal length of oesophagus is restored. This is often done together with a laparoscopic fundoplication.

If you would like to know more about this or speak to a specialist, please click here to arrange an appointment at the Victorian Specialist Surgery Centre.