Achalasia

And
Gastoesophageal Reflux Disease
(GERD)

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Introduction
Uncommon
Incidence- 1.6 cases per 1 lac
Prevalence -10 cases per 1 lac
 common in Chinese and Indian people compared
with Malay people.
Only 5% in children
Also occurs in elderly in association with malignancy
Peak incidence among age 25 and 60 yrs
No gender and racial differences

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Definition
Motility disorder of the esophagus
characterized by absence of peristalsis and
failure of relaxation of lower esophageal
sphincter
Achalasia is a failure of smooth muscle
fibers to relax, which can cause a sphincter
to remain closed and fail to open when
needed

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Cont..
Also known as cardiospasm,
megaesophagus or esophageal dystonia

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Etiology
Not clear
Autoimmune
Viral infections
Neurodegenerative(degeneration of
Myentric Plexus)

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Myentric plexus

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Clinical Manifestations
Dysphagia
Chest pain
Regurgitation
Heartburn

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Cont…
Sensation of food
sticking
Nocturnal cough
Aspiration
Weight loss

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Mechanism of esophagus

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Anatomy of LES

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Pathophysiology
Unknown causes,autoimmune,viral infections,
neurodegenerative causes or secondary achalasia

Inflammation of muscles as well as nerves in

Lower esophagus

Loss of inhibitory neurons

Hypertensive nonrelaxed esophageal sphincter

and aperistalsis

Clinical manifestations

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Investigations

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Chest X-Ray

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 Barium swallow
Rat tail
appearance/
bird’s beak

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 Endoscopy
It shows the narrowing
or obstruction of distal
part of esophagus
Also to exclude organic
cause of obstruction

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Esophageal Manometry

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Esophageal Biopsy
 extra-myenteric
changes in the
esophageal mucosa and
submucosa
The mucosa is
frequently diffusely
hyperplastic, often with
papillomatosis
 basal cell hyperplasia

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 Management
Lifestyle modifications
Pharmacological
Forceful Dilatation
Botulinium Toxin
Esophageal Myotomy

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Lifestyle modifications

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Pharmacological Management
Calcium channel blockers e.g nifedipine
Long lasting Nitrates eg. Isosorbide nitrate
Mechanism of action:-
Lowers LES pressure
Side effects:-
Headache, Hypotension and Pedal edema
 Anticholinergic,beta adrenergic agonists
and theophylline less commonly used
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Pneumatic Dilation

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Botulinium toxin

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Surgical Myotomy

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Esophagectomy
End stage achalasia
Gastric or colonic
interposition

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Management

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COMPLICATIONS

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Emerging Therapy

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 GERD
(Gastroesophageal reflux
disease
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Epidemiology
An approximate prevalence of 10–20% in Western
world
 while in Asia this was lower, at less than 5%.
The incidence in the Western world was
approximately 5 per 1000 person years.

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 GERD:DEFINITION
According to American college of
gastroenterology(ACG)
Symptoms of mucosal damage produced by
abnormal reflux of gastric contents into the
esophagus
Often chronic and relapsing
May see the complications of GERD in patients
who lack typical symptoms

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Contd…
A Condition which develops when the reflux of stomach
contents cause troublesome symptoms and/or
complications(Montreal consensus panel)

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Clinical manifestations

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PATHOPHYSIOLOGY

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Pathophysiology

Aggravating Factors in decreasing LES pressure

Impaired antireflux barrier

Reflux of gastric contents into lower esophagus

Esophageal irritation and inflammation

Sign and symptoms of esophagitis

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AGGRAVATING
FACTORS

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 Barrett’s
Esophagus:

pneumonia Esophagitis

Esophageal
Bronchitis complications
stricture

Respiratory
Asthma complication
s
Dental
erosion

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INVESTIGATIONS

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Barium swallow
Endoscopy
Ambulatory Ph monitoring
Impedance Ph monitoring
Esophageal manometry

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Barium swallow

FINDINGS
Protrusion of upper part of
stomach

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Endoscopy
Assesses LES
competence and degree
of inflammation

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 Ph Monitoring

Accepted standard

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Esophageal Manometry

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Radionuclide test

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 Management
Treatment goals include
Symptom elimination
Healing esophageal damage
Preventing complication
and relapse

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Lifestyle Modifications

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Pharmacological Management
Categories of medicines
Antacids
Histamine-2 receptor
antagonists:
May require lifelong therapy
Proton pump inhibitors
More effective than H-
2receptor
antagonists
prokinetic drugs
Coating agents
Mode of action
Neutralize gastric acid
Decrease gastric acid
secretion
 Block gastric acid
secretion
Speeds up digestion
coats esophageal mucosa
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Antireflux surgery

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Toupet repair
 In the Toupet repair, the
fundus is wrapped 270 degrees
around the distal esophagus.
 suturing the fundus on either
side of the esophagus.
Identification of the anterior
vagal branch helps prevent
incorporation into a suture.
 Suturing the lateral aspects of
the wrap to the crural edges
stabilizes the repair.
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Endoscopic Treatment

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Nursing diagnosis
Pain related to physical injuring agents caused by
esophageal spasm, distention of lower portion of
esophagus from food and fluid accumulation.
 Altered nutrition less than body requirements related to
inability to ingest foods and fluids caused by dysphagia,
reflux of gastric contents.
 Impaired Swallowing related to stricture/inflammation of
esophageal mucosal injury

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Cont…
Risk of aspiration
Risk for fluid volume deficit
Anxiety
Knowledge deficit
Risk for complications

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Expected outcome
patient will have no pain as evidenced by verbalization
of absence of pain
Adequate nutritional intake with minimal or absence
of discomfort evidenced by verbalization that eating 6
small meals/day without discomfort.
Patient will have no symptoms of aspiration
Adequate fluid volume as evidenced by skin turgour
and mucous membranes

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Cont….
Patient will have no anxiety
Patient will have relevant knowledge regarding his
disease,drugs prescribed and treatment
Patient will be free of complications
Encourage the patient compliance with his drug
regimen

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Nursing interventions
1. Relief of pain:
Encourage clients to learn relaxation techniques
Encourage clients to avoid foods and beverages that
irritate the stomach, such as alcohol
Encourage clients to use diet pd regular intervals.
Administer Antacid (magaldrate,aluminum
hydroxide).Anticholinergic (propatheline bromide,
bethanechol chloride

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Cont…
 Encourage small frequent feedings
Advise to avoid any activities that increase pain & to
remain upright for 1 to 4 hours after each meal
Elevate the head of bed 4 to 8 inch Advise to avoid
eating before bedtime
Advise that excessive use of over – the – counter
antacids can cause rebound acidity

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Cont…
2.Improving swallowing
Place in high Fowler’s position for meals and snacks;
 head and neck should be tilted forward slightly
Provide oral care before meals and snacks
Assist to select foods that require little or no chewing
and are easily swallowed
Avoid serving foods that are sticky
 Serve foods/fluids that are hot or cold instead of room
temperature

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Cont…
. Maintaining adequate nutrition
Provide eat small but frequent meals and do not
irritate.
Give solid foods as soon as possible
Provide a drink that contains no caffeine
Administer vitamins and minerals if ordered.
 Perform a calorie count if ordered.
Offer high protein, high calorie dietary supplements if
indicated

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Cont..
Consult physician about an alternative method of
providing nutrition (e.g. parenteral nutrition, tube
feedings).
Assess the pt’s hydration and nutrition status
Provide oral fluids and nutrients as needed
Encourage significant others to bring in pt’s favorite foods
unless contraindicated and eat with him/her
 Limit fluid intake with meals
Serve frequent, small meals rather than large ones
Maintain a clean environment and relaxed, pleasant
atmosphere
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Cont..
. Prevention of aspiration
Place pt. in a semi – fowler’s position
 Provide oral hygiene
Instruct pt. to avoid laughing and talking while eating
& drinking
Perform oropharyngeal suctioning

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Cont…
. Maintain body fluid volume
Observation of fluid intake and output
Observe for signs of dehydration
 Drink a glass of water to wash the back of your
esophagus at the end of every meal.
Drink eight to 10 glasses of 8 oz. water each day to stay
hydrated.

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Cont…
Reduce anxiety
Encourage clients to express their problems and fears
Help clients identify situations that cause anxiety
Teach stress management strategies

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Cont…
7. Increase the client's knowledge about the
disease
Assess client's level of knowledge
Provide the required information by using the right
words and the corresponding time
Reassure the client that the disease can be overcome

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References
 Lewis .o Brian etal.Achalasia. Textbook of medical surgical nursing assessment
and management of clinical problems 7th edition 2009 Mosby publisher ;page no
1189-1205
 Black M J, Hawks JH. Medical Surgical Nursing clinical management for positive
outcomes. 8th edition. volume 1. New Delhi: Elsevier ; 2009. 611- 613
 Polaski LA, tatro SE. Core principles and practice of medical surgical nursing. 4 th
edition . Philadelphia: WB Saunders company;1996.1022-1023
 Nettina SM. Lippincott Manual of Nursing practice. 9 th edition. New delhi:
Wolters Kluwer pvt. Ltd; 2010. 672, 1603-1604
 Lewis SM, Heitkamper MM, Dirksen SR. Medical surgical nursing, assessment
and management of clinical problems. 6th editon. Missouri: mosby publication;
2004.1189
 Smelzer SC, Bare BG, Hinkk JL, Cheever KH. Textbook of medical surgical
nursing. 11th edition. volume 1. New delhi: wolters kluwer Pvt. Ltd.;2008. 1169-1170

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Cont….
 http://www.webmd.com/digestive-disorders/achalasia?page=2
 Journal of the American college of cardiology, volume 58, issue
15, 4 october 2011, page 1635-1636
 http://www.healthline.com/health/achalasia#Prevention9
 http://www.medicinenet.com/gerd overview/page4.htm
 http://rnspeak.com/pathophysiology/achalasia-
pathophysiology-schematic-diagram/
 http://www.mayoclinic.org/diseases-conditions/gerd/basics/
treatment/con-20030640
 http://www.nature.com/gimo/contents/pt1/full/gimo56.html
 http://ses.library.usyd.edu.au/handle/2123/11810

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Contd..
Zebra F, Thetiot V, Richy F et al. Repeated pneumatic
dilations as long-term maintenance therapy for esophageal
achalasia. Am J Gastroenterol 2006;101:692–697.
Costantini M, Zaninotto G, Guirroli E et al. The laparoscopic
Heller-Dor operation remains an effective treatment for
esophageal achalasia at a minimum 6-year follow-up. Surg
Endosc 2005;19:345–351.
Kostic S, Johnsson E, Kjellin A et al. Health economic
evaluation of therapeutic strategies in patients with
idiopathic achalasia: results of a randomized trial comparing
pneumatic dilatation with laparoscopic cardiomyotomy.
Surg Endosc 2007;21:1184–1189
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