Achalasia of esophagus

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Achalasia of esophagus

ACHALASIA OF ESOPHAGUS

* Definition: It is a functional neuromuscular disorder of the esophagus

characterized by weak or absent peristalsis of the esophagus & failure
of relaxation of the lower esophageal sphincter and the cardia
during swallowing.

* Aetiology: not exactly known

1. It may be due to patchy inflammatory reaction leading to destruction

of post-ganglionic neurons of Auerbach’s plexus at the lower end of
esophagus .

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Achalasia of esophagus

2. It may be due to aquired degeneration and loss of the vagal fibres &
ganglion cells of Auerbach’s plexus at the lower end of oesophagus.

3. It may be autoimmune disorder as there is infiltration of the

oesophgus by lymphocytes.

* Pathology:

1- Oesophagus above is dilated (firstly funnel but later on sigmoid

shaped).

2- Mucosa is inflamed , congested , oedematous and ulcerated due to

stasis and esophagitis.

3- The esophagus always contains stagnant offensive fluid.

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Achalasia of esophagus

* Complications:

1- Esophagitis → ulceration & bleeding .

2- Respiratory complications due to aspiration of esophageal content.

3- Dehydration, anaemia and loss of weight are rare (due to

intermittent course ) and occurs only in long standing severe
cases.

4- Carcinoma of oesophagus (5%) after 20 years.

5- Diverticulae of the esophagus in long standing severe cases.

* Clinical Picture:

1- Usually occurs in patient 20-40 years & equal in males & females.

2- Dysphagia :

 It is the earliest and the commonest symptom .

 It is insidious, intermittent ,long standing and painless .
 Classically at first more to fluids and later to both solids and fluids
 Arrest of food is behind the xiphisternum.

 NB : In cancer esophagus , dysphagia first to solid ,

progressive with anaemia & cachexia .

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Achalasia of esophagus

3- Patient is usually fairly nourished ( intermittent course ) in early

cases.
4-chest pain & odynophagia ( painful swallowing ) may occur early
due to dilatation of the esophagus and decrease gradually as the
degree of dilatation increase .
5- Sever continuous Retrosternal pain may occur late due to
oesophogitis .
6- Regurgitation of foul smelling saliva & undigested food specially by
night .
7- Halitosis : Bad odour of the breath .
8- Picture of complications in neglected cases (mention) eg.
pulmonary symptoms as cough , wheezes , pneumonia etc…..
* Investigations:
1- Plain chest X-ray may show a fluid level in the thorax, widening of
mediastinum by dilated esophagus or aspiration pneamonia.

A chest X-ray showing achalasia ( arrows point to the outline of the massively dilated esophagus )

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Achalasia of esophagus

2- Barium swallow: is most important investigation & shows :

 Early , hold up of barium at the lower end of esophagus .

 Huge dilatation and later on tortuosity ( sigmoid shape )of the

oesophagus with a fluid level.

 Funnel, pencil or Hen’s beak shaped narrowing of lower end of

oesophagus at or below the diaphragm.

 No gas bubble in fundus of the stomach due to continuous

stagnation of fluid in the esophagus .

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Achalasia of esophagus

2- Esophagoscopy: Show

 Hugely dilated esophagus containing dirty retained food & fluid.

 Mucosa is congested and ulcerated.

 Cardiac orifice is very narrow & does not relax .

 Exclude carcinoma.

3- Manometric studies (best investigations in early cases ) show

weak peristaltic waves in the oesophagus after deglutition with failure
of relaxation of the cardia in response to swallowing efforts.

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Achalasia of esophagus

* Treatment:

A) In mild cases:

1. Medical treatment: by nitrate or calcium channel blockers are of

limited temporary benefit.

2. Dilatation of the lower esophageal sphincter & cardia by

hydrostatic or pneumatic bag, through an oesophagoscope.

 Idea : Inflation of balloon to rupture the circular muscle layer

to relieve the distal esophageal obstruction .

 Method : the esophagus is dilated to a diameter of 3 cm and

the balloon is maintained for 3-5 minutes .

 Complications : rarely hemorrhage or perforation .

 Results : 70% of patients remain well for one year and the
remaining 30% remain well for 1-5 years .
3. Recently , injection of botulinum toxin in the wall of the narrow
segment of the esophagus is safe and can be performed in an
outpatient setting nearly with the same results as balloon
dilatation.

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Achalasia of esophagus

B) In severe cases:

 The safest , most reliable and fastest treatment is

laparoscopic Heller’s operation (esophagocardio-
myotomy) :

 Method : Longitudinal incision is made in the muscle coat of

lower 7 cm of esophagus and upper 2 cm of stomach n until the
mucosa bulge through the incision .

 Nowadays this operation is done though open or

laparoscopic procedure .

 Complications : reflux esophagitis therefore some surgeons

add antireflux procedure following myotomy .

Laparoscopic lower esophageal surgery

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Achalasia of esophagus

Heller’s operation

Antireflux procedure following myotomy

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Achalasia of esophagus

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