ACHALASIA

GROUP 2 BSN 3A
What is Achalasia all about.

Achalasia is an esophageal smooth muscle

motility disorder that occurs due to a
failure of relaxation of the lower
esophageal sphincter. This disorder can
occur at any age, but unusual before the
age of 15.
TYPES OF ACHALASIA
A. Ty p e 1 a ch a l a s i a i s c a l le d c l a ss ic
a c h a la s i a . Wi t h t h i s t y p e , t h e e s o p h a g u s
mu sc l e s b a r e ly c o n t ra c t , s o f o o d mo ve s
d o wn b e c a u se o f gr a v it y a l o n e .
B . I n Ty p e 2 a c ha l a s i a , p re ss u re b u il d s u p in
t h e e s o p h a g u s , ca u s i n g it t o be co me
c o mp re s se d . Th i s i s t h e mo st c o mmo n t yp e o f
a c h a la si a , a n d i t o f t e n c au s e s mo re s e ve r e
s ymp t o ms t h a n t y p e 1 .
TYPES OF ACHALASIA

C.Type 3 achalasia is called spastic

achalasia because there are abnormal
contractions at the bottom of the
esophagus where it meets the stomach.
This is the most severe type of
achalasia.
Etiology

 Achalasia is thought to occur from the degeneration of the

myenteric plexus and vagus nerve fibers of the lower esophageal
sphincter. There is a loss of inhibitory neurons containing vasoactive
intestinal peptide (VIP) and nitric oxide synthase at the esophageal
myenteric plexus, but in severe cases, it also involves cholinergic
neurons. The exact etiology of this degeneration is unclear though
many theories have been proposed. These theories include an
autoimmune phenomenon, viral infection, diseases, and genetic
predisposition.
Etiology

Risk Factors

• Viral Infection
Signs and Symptoms
• Diabetes Mellitus
• Dysphagia
• Chagas Disease
• Weight loss
• Regurgitation
• Heart Burn
• Sense of fullness
• Pneumonitis and chronic cough
Pathophysiology
NON-SURGICAL TREATMENT

Medical Management: The overall goal of management is to relieve the signs and symptoms, prevent the occurrence of complication and
improve functional status and quality of life.

Specific objectives of medical management include the following:

•To r e l i e v e t h e p a t i e n t ' s s y m p t o m s
•To i m p r o v e e s o p h a g e a l e m p t y i n g
•To p r e v e n t f u r t h e r d i l a t a t i o n o f t h e e s o p h a g u s .
•To w e a k e n t h e l o w e r e s o p h a g e a l s p h i n c t e r ( L E S ) m u s c l e t o t h e p o i n t t h a t i t n o l o n g e r p o s e s a b a r r i e r t o t h e p a s s a g e o f f o o d .
 Medical management

1) Pneumatic dilation.

 It is an endoscopic therapy for achalasia. An air-

filled cylinder- shaped balloon disrupts the muscle fibers
of the lower esophageal sphincter, which is too tight in
patients with achalasia.

2) Botox (botulinum toxin type A).  

It addresses this imbalance by  blocking

acetylcholine release from excitatory neurons acting on the
lower esophageal sphincter. This results in a decrease in
lower esophageal sphincter tone that can allow improved
esophageal emptying.
Medical management

3) PHARMACOLOGIC MANAGEMENT

Drug Of Choice

1.Calcium Channel Blockers :

It decreases calcium entry and reduce the pressure in lower esophageal sphincter.

• Nifedipine (Adalat, Procardia):

It relaxes the muscles of the lower esophageal sphincter, allowing food and liquid to pass
more easily into the stomach.


Medical management

 Nursing Considerations

• Encourage client to avoid grapefruit juice (May increase bioavailability of drug.

• Instruct client not to chew or crush, doing so can release all of the drug at once,
increasing the risk of side effects.

• It is best to take this tablet on an empty stomach.  

• Tell the client to eat slowly, taking small bites, and avoiding swallowing large
volumes of food or liquid.
Medical management

2. Nitrates:

It relaxes muscle, and they are used to try to relieve the symptoms; dysphagia,
regurgitation of food, retrosternal pain and so on.

• Nitroglycerin (Nitrostat):

It helps to relax the muscles of esophagus that makes swallowing easier.

Medical management

 Nursing Considerations

• Give sublingual preparations under the tongue or in the buccal pouch. Encourage
patient not to swallow.

• Give sustained-release preparations with water.

• Do not chew or crush the timed-release preparations; take on an empty stomach.

• Contraindicated with allergy to nitrates, severe anemia, early MI, head trauma,
cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation.
Dietary Changes

 Adopt a soft textured diet. For more severe cases, a pureed or liquid diet may be needed.

 Incorporate soft, cooked, mashed or pureed foods; soups, smoothies and crock-pot meals (tender
meats and vegetables).

 Smoothies and protein shakes are especially helpful when appetite or intake is low.

 Sip small amounts of liquids with meals to ease swallowing and help food slide down the
esophagus.

• Enjoy room temperature or warm liquids.

• Avoid ice cold drinks which can cause muscle spasms.

 Add sauces and gravies to moisten food.

 Take small bites, chew food thoroughly and limit stressful distractions at mealtimes.

 Do not go to bed immediately after a meal. Allow about three hours after eating before laying
down to prevent regurgitation and heartburn.
Diagnostics Procedure

a.Esophageal manometry

This test measures the rhythmic muscle contractions in the esophagus when swallow, the
coordination and force exerted by the esophagus muscles, and how well the lower esophageal
sphincter relaxes or opens during a swallow.

b. Barium swallow test

This test involves swallowing a chalky-tasting, thick mixture of barium while x-rays are taken.
The barium shows the outline of the esophagus and lower esophageal sphincter (LES).

c. Endoscopy

This test is usually recommended for people with suspected achalasia and is especially useful
for detecting other conditions that can mimic achalasia such as cancer of the upper portion of the
stomach.
Diagnostics Procedure

d. Chest x-rays

A chest x-ray may be done to determine aspiration pneumonia as well as to determine

the extent and its location.
Nursing Management

ASSESSMENT: The nurse needs to obtain a history noting the symptoms the
client is experiencing. The onset and duration of symptoms with factors that
aggravate symptoms should be assessed. The nurse should note any methods the
client uses for relief. Respiratory symptoms also should be assessed be- cause the
respiratory tract can be affected with reflux or regurgitation. The nurse should
assess the client's nutritional status, noting any weight changes and the effects of
esophageal symptoms on dietary habits and the client's respiratory status.
Nursing Management

Nursing Diagnosis:

•Altered Nutrition: Less than Body Requirements related to dysphagia

•Acute/Chronic Pain, related to episodes of gastric reflux

•Knowledge deficit related to preoperative preparation

Nursing Management

PLANNING:

•The client will maintain adequate nutritional intake.

•The client will experience a decrease in pain or decreased pain.

•The client will understand and be adequately prepared for surgery.

 Nursing Management

IMPLEMENTATION:

• The nurse should consult with the client concerning dietary habits and assess the client's intake
of nutrients daily. A baseline weight should be obtained, and the client should be weighed daily.
The nurse should teach the client about changes in dietary habits that may relieve symptoms.

• As stated, pain can be decreased or relieved using medications, dietary changes, and
repositioning the client. The nurse should assess the client every shift to determine whether the
use of medications, changes in diet, and positioning were effective in controlling or relieving
pain.

• Clients undergoing esophageal dilation should be told that they will be awake during the
procedure. A local anesthetic will be sprayed on the throat, and the client may receive an
analgesic or tranquilizer. The client should take long slow breaths during the passage of the
bougies. As the bag is inflated, the client may feel a brief feeling of discomfort. Esophageal
dilatation is often performed on an outpatient basis.
 Nursing Management

IMPLEMENTATION:

• Esophagomyotomy is a more complex procedure. The client will require a general anesthetic and
remain hospitalized for several days. The nurse should instruct the client undergoing an
esophageal procedure about all usual preoperative procedures, such as taking nothing by mouth
after midnight, intravenous fluids, and preoperative medications. The nurse should also dis- cuss
pain control, chest tubes, drains, surgical dressings, and the presence of a nasogastric or gastric
tube.
Nursing Management

EVALUATION:

• The client maintains adequate nutritional intake as evidenced by maintenance of

ideal body weight or gaining back any weight lost at a rate of 1 pound/week.

• The client will experience a decrease in pain or decreased of pain as evidenced

by the client verbalizing a decrease in or absence of pain and the client's ability
to maintain oral intake.

• The client will understand and be adequately prepared for surgery as evidenced
by client questions and statements of understanding.
Thank you