Overview
Achalasia Cardia is primarily a disease of esophagus in which lower end of esophagus (Lower Esophageal Sphincter-LES) does not relax properly in response to food intake and there is inappropriate and ineffective motility (Peristalsis) of the body of esophagus. This leads to impaired emptying of esophagus and gradual dilatation of this tubular structure. There is thickening of lower end along with increase in fibrous tissue in muscular layer of esophagus.
Signs and symptoms
- Mostly patient complains of gradually increasing difficulty in swallowing food (both solids and liquids)
- Feeling of stickiness in throat
- These symptoms tend to increase whenever there is stress or cold
- Undigested food tends to come back into mouth (Regurgitation)
- Chest infections / pneumonia tend to occur due to aspiration of food into windpipe
- Heartburn / acidity sensation
- Severe retro sternal chest pain in 30-40% of patients
- Weight loss in advanced esophageal disease
- Patients with achalasia are at increased risk for esophageal cancer
Tests and diagnosis
Barium meal or esophagogram
- Bird beak appearance is the typical presentation in which there is tapering of lower end of esophagus after massively dilated middle part of it
- Air-Fluid levels are seen in the middle part of esophagus
- Image intensifier (Fluoroscopic) evaluation suggests improper motility (peristaltic) activity
Upper GI endoscopy
- Undigested food particles along with ingested fluid filled esophagus
- Lower end of esophagus fail to open even after air insufflation
Manometry
- Considered the gold standard in the diagnosis of this disease
- There is failure of relaxation of lower end of esophagus
- Pressure at lower end may be high but it may be normal also
Endoscopic ultrasound
Thickened muscle layers in the lower part of esophagus.
CT scan
CT scanning with oral contrast enhancement may demonstrate the gross structural esophageal abnormalities associated with achalasia, especially dilatation, which is seen in advanced stages.
Treatment
Treatment options for achalasia include pharmacologic, mechanical, botulinum toxin, and surgical-based therapies.
Four main classes of drugs have been used for this purpose and include the following:
- Calcium channel blockers - Nifedipine and verapamil
- Anticholinergic agents - Cimetropium bromide
- Nitrates - Isosorbide dinitrate
- Opioids – Loperamide
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