ACHALASIA ESOPHAGI

Definition: the achalasia is a neuromuscular disease of the esophagus which is characterized

with incomplete relaxation and higher pressure of the DES ( down esophageal sphincter),
lacking peristalsis in the distal part of the esophagus and higher intraesophageal pressure in
comparison to the gastrical.
Incidence: the esophageal acahalasia is a rare disease with approximate frequency of 0,6-1
new cases in 100 000 people for a year. It can develop in every age but most frequent is in
the age 30-60 years. It affects equally both sexes.
Ethiopathogenesis: the etiology of the esophageal achalasia is unknown. The latest
researches accept that a number of mechanisms are responsible for the manifestation of the
disease – autoimmune, genetical, viruses and hormones. The major pathophysiological
mechanism is denervation of the esophagus with decreasing the number of the ganglionar
cells, mainly in the DES. Degenerative process with mononuclear cell infiltration reveals or
total peplacement with cicatricial tissue of plexus myentericus (Auerbachi).
Clinical picture:
Dysphagia is the major clinical sign of the acahalasia. Dysphagia is the earliest and
most frequent manifestation of the disease. It appears suddenly, has different
heaviness, permanent or intermitting character. In most of the cases it as a progressive
running and appears after intake both of solid food and liquids. Dysphagia often is
proviked by emotional stress. It exists 8-10 years after determining of the diagnose.
Regurgitation of undigested food is the second symptom, determined by its
frequency. In most of the cases it appears in the nights in sleep or immediately after
eating.
Retrosternal pain or burning behind the chest bone are caused by the dilatation or
stasis in the esophagus.
Pulmonary symptoms – night cough, dispnea, hiccup, pulmonary infections, chronic
respiratory insufficiency are a result of regurgitation of aspirated liquids.
Complications:
Nutritional – progressive weight loss;
Respiratory - pulmonary infections, pneumofibrosis, caused by frequent episodes of
aspiration of esophageal content, chronic respiratory insufficiency.
Esophageal – esophagitis, esophageal cancer.

Diagnose – it is confirmed by:

Anamnestical data;
The X-ray examination;
The endoscopy examination;
The changes, found by esophageal manometry are pathognomonical.
The X-ray examination with barium swallow finds out:
 Dilatated esophagus without peristalsis, with hydraeric level, caused by stasis
of secretion and undigested food in the upper part of the esophagus;
 Smooth distal stenosis similar to a beak;
 Lacking air ballon in the stomach;
 The X-ray changes are missing in the early stages of the disease;
The endoscopy with biopsy and histological examination are obligatory for the exclusion of
esophageal cancer, lymphoma or benign stricturas.

Differenrial diagnose:
 Diffuse esophageal spasm;
 Secondary achalasia due to other diseases;
 Sclerodermia;
 “Nut-cracker” like esophagus;
 Esophageal cancer or cancer of the cardia;
 Lymphoma]
 Infiltrative process from outside the esophageal wall;
Treatment-its purpose is to recover the peristalsis and to diminish the pressure in the DES to
normal values.
 Conseravative treatment. It is done with calcium antagonists and nitrates. Clinical
improvement is reached in about 70 % of the cases. The medicines are taken 15-45
min. before eating(Nifedipin in a dose 10 mg-3 times daily; Isosorbide dinitrate-15 mg
daily
 Pneumatic dilatation with hydrostatic balloon catheters under endoscopic control is
effective in 75-85 % of the cases and is a method of choice. The balloon dilatation is
the only possible treatment in the advanced age, cardiovascular and pulmonary
diseases and high-grade esophageal dilatation. According to different authors
favourable results are reached in up to 90 % of the cases. The riscs and complications,
connected with this treatment are few.
 Myotomia by Heller is the surgical alternative, for the treatment of esophageal
achalasia.
 ESOPHAGEAL CANCER

Definition: malignant esophageal disease. It takes the 8-9 th. Position from the malignant
epithelial tumors in the world and 6 th place as cause for death from these neoplasms. The
esophageal cancer is a significant health problem because of its high prevalence, late diagnose
and relevantly uneffective therapy.
Epidemiology: the men are hit more often (men: women= 4:1) as well as the advanced age.
Its incidence is different in the different geographical regions. In Europe and the USA it is
6,5-12 per 100 000 population, and in some countries of Asia and Africa it reaches 100 per
100 000 population.
Pathology: the esophageal cancer can manifestate as flatcell tumor(in 95 % of the cases) or as
adenocarcinoma- it is very rare and originates from the metaplastic cells of the Barret
esophagus.
Etiology: it is unclear. The following factors are of greater importance:
1. By the flatcell carcinoma:
 Combination of smoking and alcoholism;
 High content of nitrosamines and musts in the food and low content of
vitamins(B and C);
 Deficiency of microelements, especially of Molibden and Zinc in the soils;
 Use of opium;
 Congenital esophageal anomalies;
 Esophageal ahalasia;
 Leucoplacia;
 Corosive and other strictures of the esophagus;
 Pharyngeal cancer;
2. By the adenocarcinoma-the ethiology is connected with the Barrets esophagitis and the
villous adenomas. The incidence of esophageal cancer by the Barrets esophagus is 40
times higher than the one in the total population. From the other side however the
follow up of patients with Barrets esophagus shows that the esophageal cancer occurs
in only 0,5-1 % per year. The risk of esophageal cancer grows with the growth of
heaviness of the GERD.

Clinical picture:
 Progressive dysphagia – main symptom, occurring initially after consumption of solid
food and later after intake of liquids.
 Weight loss;
 Anorexia;
 Pain behind the chestbone;
 Hematemesis;
 Hypersalivation;
 Purulent breath;
 Pulmonary symptoms, caused by bronchoesophageal fistulas;
 Eructation;
 Secondary achalasia(very rare);
 By spreading in neighbour organs symptoms of mediastinitis, cardial complains,
Claude-Bernard- Horner syndrome (myosis, ptosis, enophthalmus).

Diagnosis
 Specific symptoms lack by the physical examination;
  The anamnestical data point towards the diagnose esophageal cancer;
 In the advanced stages cahexia, hepatomegaly and cervica lymphadenomegaly(from
metastases) are found.
 The stage of infiltration of the wall and engagement of the local lymph nodules are
determined through endoscopic sonography. The stadium according to the TNF
classification is determined.
 The CT has the advantage to show the extraesophageal localization of the disease;
 MRI=CT;
 By tracheal infiltration the bronchoscopy is method of choice.
Therapy-the radical treatment is operative.
Endoscopic radical therapy is a method of choice for premalignant lesions as dysplasia and
mucosal cancer without invasion of the lymph nodules and by well differentiated small sized
tumors.