Achalasia

Achalasia is a swallowing disorder that affects the esophagus. The esophagus is a tube that connects the back of throat to stomach. Food and liquid go down the tube when swallow. In achalasia, the muscles of the esophagus don’t work well at pushing food or liquid down into stomach.

The valve at the lower end of esophagus called the lower esophageal sphincter also has a problem. The ring of muscle in the valve does not relax enough to let food and liquid pass easily from the esophagus into the stomach. Achalasia means “failure to relax.”

Achalasia often develops slowly. It becomes harder to swallow food and drinks over time. Achalasia has no cure. But Symptoms can be controlled with Treatment.

In most cases, it's caused by loss of the nerve cells that control the swallowing muscles in the esophagus. Don’t yet know why these nerve cells are lost. In rare cases, achalasia is caused by a tumor.

Achalasia can occur at any age. But it happens most often between ages 30 and 60. Men and women are equally at Risk.  Risk factors may include:

  • Having certain genes
  • Having a problem with  immune system that Causes it to attack nerve cells in  esophagus
  • Having herpes simplex virus or other viral infections
  • Having Chagas disease. This is an infection caused by a parasite. The parasite is passed to people through the bite of an insect. Chagas disease is mainly found in poor rural areas of Mexico and Central and South America.

Symptoms can occur a bit differently in each person. They develop over time as the esophagus becomes wider and weaker. Symptoms can include:

  • Trouble swallowing food (dysphagia)
  • Food or liquid flowing back up into  throat (regurgitation)
  • Waking up at night coughing or choking due to regurgitation
  • Heartburn
  • Chest pain or pressure
  • Trouble burping
  • Hiccups
  • Weight loss

Treatment can help prevent long-term Complications such as:

  • Aspiration pneumonia. This is caused when food or liquids in esophagus back up into throat and breathe them into lungs.
  • Esophageal perforation. This is a hole in the esophagus. It may happen if the walls of esophagus become weak and bulge. It may also happen during Treatment. Esophageal perforation may cause a life-threatening infection.
  • Esophageal cancer. People with achalasia are at higher Risk for this type of cancer.

No evidence available in Research how to prevent achalasia.

 

How is it diagnosed?

Symptoms and health history and physical exam.  Tests such as:
  • Endoscopy. A flexible lighted tube is passed through mouth to look into esophagus and the lower esophageal sphincter (LES).
  • Esophogram. This is a type of X-ray that takes pictures of esophagus while swallowing a thick contrast material called barium or barium table. The radiologist looks for signs of achalasia. These include widening of the esophagus, incomplete emptying, and tightness of LES.
  • Manometry. A thin tube that measures pressure is passed through nose down into esophagus. Pressure measurements are taken as patient swallow sips of water. This test can show if the muscles in esophagus are weak and don’t work well. The test can also show pressure buildup at LES. This test confirms a Diagnosis of achalasia.

How is it treated?

There's no known cure for achalasia. But Treatments can manage symptoms. Treatment can:
  • Ease  Symptoms
  • Open up  LES so  esophagus empties more easily
  • Help prevent Complications

May also need repeat Treatments. Treatment may include the following.

  • Pneumatic dilation
    This is an outpatient procedure done under anesthesia. We look into esophagus through an endoscope and passes a small balloon through the LES. The balloon is then inflated using an X-ray to guide it. May need more than 1 Treatment to get relief.

  • Botulinum toxin injection
    Botulinum toxin is a medicine that can paralyze muscles. It can be injected into the muscles that control LES. This helps to relax the valve opening. This procedure is done during endoscopy. Patient may be asleep or partly asleep with sedation through an IV (intravenous line). The benefits often go away in 3 to 12 months. So the procedure needs to be repeated.

  • Surgery
    Surgery may be done to open LES. This is called myotomy. During myotomy, the muscles of the LES are cut. This procedure can be done using a minimally-invasive approach called laparoscopy. A few small cuts (incisions) are made. A thin, lighted tube called a laparoscope is used. This scope lets allow to see inside body and work through the small incisions. At the same time, surgeon may do a procedure called a fundoplication to help minimize acid reflux (gastroesophageal reflux disease, GERD) after the procedure. This is done by wrapping the very top of the stomach around the lower part of the esophagus. This type of surgery often gives long-term relief from achalasia Symptoms.

  • Peroral endoscopic myotomy (POEM)
    An endoscope inserted through mouth and down to esophagus. An incision is made in the inner lining of the esophagus. The endoscope then enters between the layers of the esophagus to the muscle. Part of the muscle layer is removed in the lower part of the esophagus, the LES, and the upper part of the stomach. This decreases the tightness from the LES. It allows food and liquid to pass from the esophagus into the stomach more easily. POEM is considered less invasive and recovery is rapid. But it results in frequent acid reflux and most likely will need Treatment for GERD after the procedure.

  • Medicines
    There are 2 medicines often used to treat achalasia. They are calcium channel blockers and long-acting nitrates. These medicines are used if surgery is not a choice or if Symptoms continue after getting botulinum toxin injections.

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