ACHALASIA

Created By :

Group 5

1. Anggel Putri Inten Murtia (21119048)

2. Aurellia Zafirah Abeer Jacinda (21119050)
3. Dela Putri Asmarita (21119053)
4. Deni Firmansyah (21119054)
5. Fajar Wahyudi (21119057)
6. Intan Pramono (21119061)
7. Marisa Sugandi (21119068)
8. Septiana Adelia (21119082)

Lecturer : Sukron, S.Kep.,Ns,MNS

INSTITUTE OF HEALTH SCIENCE AND TECHNOLOGY

MUHAMMADIYAH PALEMBANG

2021
 PREFACE

First of all, thanks to Allah SWT because of the help of Allah, writer finished
writing the paper entitled “Achalasia” right in the calculated time. The purpose in
writing this paper is to fulfill the assignment that given by Mr. as lecturer in
Surgical Medical Nursing (KMB).

in arranging this paper, the writer trully get lots challenges and obstructions but
with help of many indiviuals, those obstructions could passed. writer also realized
there are still many mistakes in process of writing this paper.

Because of that, the writer says thank you to all individuals who helps in the
process of writing this paper. hopefully allah replies all helps and bless you all.the
writer realized tha this paper still imperfect in arrangment and the content. then
the writer hope the criticism from the readers can help the writer in perfecting the
next paper.last but not the least Hopefully, this paper can helps the readers to gain
more knowledge about Sugical Medical Nursing (KMB).

Palembang, February 19th, 2021

Author

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 CONTENTS

Cover

Preface ...................................................................................................... i

Contents .................................................................................................. ii

CHAPTER I INTRODUCTION

A. Background ......................................................................................... 1

B. Purpose Of Writing ............................................................................ 1

C. Problem Formulation .......................................................................... 1

CHAPTER II DISCUSSION

A. Definitions Of Achalasia ................................................................... 2

B. Anatomy Physiology ......................................................................... 3
C. Sign and Symptom Of Achalasia ..................................................... 4
D. Pathophysiology Of Achalasia ......................................................... 5
E. Complications of Akalasia ............................................................... 6
F. Management Of Achalasia ............................................................... 6
G. Nursing Care Plans ............................................................................ 9
CHAPTER 3 CONCLUDES
A. Conclusion ........................................................................................ 12
B. Suggestions ....................................................................................... 12

BIBLIOGRAPHY ............................................................................... 13

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 CHAPTER I

INTRODUCTION

A. Background

At this time, the modern era, more and more diseases that arise due to
human lifestyle and due to natural factors. One of them is Akalasi, which is a
decrease in the function of the esophagus which causes choking when eating or
drinking, this disease cannot be transmitted but can occur in all genders.

Achalasia disease is more attacking people who are elderly so they need
special care because it will disturb our old age, so knowledge is needed to treat
and better to prevent this disease from an early age.

Therefore, this disease is very interesting to discuss because it is very close

to our daily lives. This disease can certainly damage the psychological and
psychosocial aspects of sufferers, and holistic nursing care and health
education is needed to prevent this disease.

B. Purpose Of Writing
This paper was prepared with the aim of providing an overview, a more in-
depth explanation of this esophageal acalacia disease. It is hoped that the
community can carry out early prevention and treatment in an appropriate way.

C. Problem Formulation
1. What causes esophageal acalacia disease?
2. What are the symptoms and treatment of esophageal acalacia?
3. How many classifications are esophageal acalacia?
4. What is the pathophysiology of esophageal acalacia?
5. How is nursing care for esophageal acalacia disease?
6. How is health education for oesophageal acalacia?

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 CHAPTER II

DISCUSSION

A. Definitions Of Achalasia
Achalasia is an abnormality function of the muscles or nerves in the
esophagus which causes difficulty swallowing or sometimes cause chest pain.
The underlying problem is weakness of the lower part of the esophagus and
failure of the LES to open and create food difficulty to get into gastric.
Pathological investigations explained there is an abnormality in the ganglion
plexus Auerbach in the esophagus of a patient with achalasia. Electron
microscope shows non-specific subcellular changes on nerve fibers, including
nuclear inclusions and cytoplasm, as well as changes in smooth muscle. The
cause of achalasia is unknown. The main problem with this disorder is
interference LES. No mutations were identified the chromosomes underlying
this disease.

Achalasia was a condition marked by peristaltic movement absent in lower

esophageal sphincter and segment that hypertonic result in imperfect relaxation
during food ingestion. Achalasia incidence did not differ between men and
women, account for 1 in 100,000 people every year with prevalence of 10 in
100 people, unrelated specifically with ethnic, and has its highest incidence on
30-60 age group. Based on its etiology, it was divided into primary and
secondary Achalasia, while based on its motility, it was into hypermotil,
hypomotil, and amotil achalasia. Until present, several therapeutic modalities
were available to treat Achalasia, among them was pharmacology therapy,
botulinum toxin injection via endoscopy, pneumatic dilatation, Heller
myotomy surgery, and per oral endoscopy myotomy (POEM).

Achalasia is a primary motility disorder in which insufficient relaxation of

the lower oesophageal sphincter (LOS) and absent peristalsis result in stasis of
ingested foods and subsequently, lead to oesophageal symptoms of dysphagia,

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regurgitation, chest pain or weight loss. Achalasia occurs as an effect of

destruction of enteric neurons controlling the LOS and oesophageal body
musculature by an unknown cause, most likely inflammatory. Idiopathic
achalasia is a rare disease and affects individuals of both sexes and all ages.
The annual incidence is estimated between 1.07–2.2 cases per 100,000
individuals with prevalence rates estimated between 10–15.7 per 100,000
individuals.

Achalasia is a primary esophageal motor disorder of unknown etiology

characterized by degeneration of the myenteric plexus, which results in
impaired relaxation of the esophagogastric junction (EGJ), along with the loss
of organized peristalsis in the esophageal body. The criterion standard for
diagnosing achalasia is high-resolution esophageal manometry showing
incomplete relaxation of the EGJ coupled with the absence of organized
peristalsis. Three achalasia subtypes have been defined based on high-
resolution manometry findings in the esophageal body. Treatment of patients
with achalasia has evolved in recent years with the introduction of peroral
endoscopic myotomy. Other treatment options include botulinum toxin
injection, pneumatic dilation, and Heller myotomy. This American Society for
Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-
based recommendations for the treatment of achalasia, based on an updated
assessment of the individual and comparative effectiveness, adverse effects,
and cost of the 4 aforementioned achalasia therapies.

B. Anatomy Physiology
The achalasia or esophagus anatomy is innervated by sympathetic and
parasympathetic innervation (nervusvagus) from the esophageal plexus or what
is commonly called the Auerbach myenteric plexus, which is located between
the longitudinal and circular muscles along the esophagus. The esophagus has
3 functional parts. The very top is the upper esophagealsphincter (upper
esophageal sphincter), a ring of muscle that forms the top of the esophagus and
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separates the esophagus from the throat. This sphincter always closes to
prevent food from the main part of the esophagus from entering the throat. The
main part of the esophagus is called the body of the esophagus, a muscular tube
about 20 cm long. The third functional part of the esophagus is the lower
esophageal sphincter (lower esophageal sphincter), a ring of muscle located at
the junction of the esophagus and stomach. Like the upper sphincter, the lower
sphincter always closes to prevent food and stomach acid from regurgitating
into the esophageal body. The upper sphincter relaxes during the swallowing
process so that food and saliva can enter the upper part of the esophageal body.
Then, the muscles of the upper esophagus that lie below the sphincter contract,
pressing food and saliva further into the esophagus. Contractions, called
peristalsis, will bring food and saliva down into the stomach. When this
peristaltic wave reaches the lower sphincter, it opens and the food enters the
stomach. of three phases, namely:
1. Oral phase, food in the form of a bolus due to mechanical processes moving
on the dorsum of the tongue towards the oropharynx, the mole palate and
the upper part of the posterior pharyngeal wall are raised.
2. Pharyngeal phase, swallowing reflex occurs (involuntary), pharynx and
fangs move upward due to contraction m. Stilo pharyngeal, m.
Salfingopharynx, m. Thyroid and m. Palatopharynx, adituslarynx covered
by epiglottis and laryngeal sphincter.
3. Esophageal phase, the phase of swallowing (involuntary) displacement of
the food bolus distally due to relaxation of the m.Krikopharynx, at the end
of the lower esophageal sphincter phase opens and closes again when the
food has passed.
C. Sign and Symptom Of Achalasia
Sign and symptoms of achalasia generally appear gradually and worsen over
time. Signs and symptoms may include:
1. Inability to swallow (dysphagia), which may feel like food or drink is stuck
in your throat.
2. Regurgitating food or saliva
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3. Heartburn
4. Belching
5. Chest pain that comes and goes
6. Coughing at night
7. Pneumonia (from aspiration of food into the lungs)
8. Weight loss
9. Vomiting

D. Pathophysiology Of Achalasia
The pathophysiology of achalasia results from degeneration of the
esophageal ganglia cells resulting in the loss of inhibitory neurons in the
muscle layer of the esophagus. Also, an imbalance of inhibitory and excitatory
neurons that regulate peristalsis and closure of the lower esophageal sphincter.
Various factors contribute to this achalasia incident.
1. Esophageal Ganglia Cell Degeneration
The pathophysiology of achalasia is associated with loss of function of the
ganglia cells in the myenteric plexus of the distal esophagus and lower
esophageal sphincter. The neural degeneration that occurs can be caused
by various factors, such as autoimmune, genetic, or viral infection. The
inflammatory reaction that occurs in the esophagus causes the production
of T lymphocytes to increase and infiltrate the ganglia cells, causing
damage to degeneration. Abnormal histopathological features are found in
the Auerbach plexus located in the esophagus. Ganglia cells are absent in
the distal esophagus in a patient with achalasia. In addition, the distal
esophageal mucosa and LES were found to have infiltration of T
lymphocytes, mast cells, plasma cells, and eosinophils. The pathogenesis
of involvement between inflammatory cells and neuronal damage that
occurs until now is still not clear whether it is a causal relationship.
2. Esophageal excitatory and inhibitory neurotransmitter imbalances
Degeneration of these ganglia cells causes dysfunction of inhibitoric
neuron cells located in the distal esophagus and lower esophageal
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sphincter. These neuron cells use nitric oxide and vasoactive intestinal
peptide as neurotransmitters. The dysfunction of these neurons results in
an imbalance between excitatory and inhibitory neurotransmitters. This
imbalance results in impaired relaxation of the lower esophageal sphincter,
hypercontractility of the distal esophagus, and impaired contraction of the
distal esophagus. This esophageal contractility disorder will run
progressively and cause loss of motility from the esophagus.
3. Abnormality In Muscle Layer And Esophageal Dilation
The inflammatory cells found in the Auerbach plexus are believed to
spread to the surrounding muscle layers, causing damage to the muscle
layer. Changes in the structural layer of the muscle that occur cause
dilation of the esophagus.
This esophageal dilation is of late grade and of high degree of severity,
resulting from gradual damage. It also causes complications from nutrition
due to food stasis and food regurgitation. Muscle hypertrophy is also seen
in the esophagus due to excess contraction of the esophagus to compensate
for sphincter obstruction. Muscle hypertrophy is also generally
accompanied by degeneration, fibrosis and eosinophilia.
E. Complications of Akalasia
Akalacia left untreated can lead to a number of complications, including:
1. Aspiration pneumonia, which occurs due to the entry of food or drink into
the lungs, causing infection.
2. Esophageal perforation or tearing of the patient's esophagus.
3. Esophageal cancer.
F. Management Of Achalasia
Management for achalasia is pneumatic balloon dilatation or laparoscopic
myotomy. If it is not possible to do pneumatic balloon dilatation, an
endoscopic injection of botulinum toxin can be administered or nifedipine and
nitrate drugs. In patients with chronic achalasia, the management of achalasia
tends to prioritize prevention of chronic aspiration. [4,9,12]
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1. Non Pharmacological Therapy

Based on the recommendations of the American Clinical
Gastroenterology (ACG) pneumatic balloon dilatation or laparoscopic
myotomy is performed as the definitive management of achalasia. Non-
pharmacological management tends to respond well to achalasia
complaints, although the recurrence rate is still possible. Surgical
management of achalasia tends to vary, but in general, the treatments used
are pneumodilation, laparoscopic Heller myotomy, and Per Oral
endoscopic myotomy. [1,4,9,12]
2. Pneumodilation
In pneumatic balloon dilatation, the ballon is inflated across the lower
esophageal sphincter, resulting in rupture of the surrounding muscle,
which can repair the muscle layer that has abnormal contractions. The
goal of this therapy is to reduce the pressure of the lower esophageal
sphincter by applying pressure to the lower esophageal sphincter using
noncompliant polyethylene balloons. Pneumatic dilation therapy can be
given on an outpatient basis for 2-6 hours and can return to normal
activities the next day. Complications caused by pneumodilation therapy
generally include perforation of the lower esophageal sphincter.
Pneumodilation therapy is recommended for patients with achalasia type 2
and the age does not exceed 60 years. This is because complications are
more common in patients aged 60 years and over.
3. Laparoscopic Heller Myotomy (LHM)
In LHM therapy, the lower esophageal sphincter is operated on to reduce
the pressure so that it can relax properly. LHM therapy is good for
patients younger than 40 years, achalasia type 2, lower esophageal
sphincter resting pressure> 30 mmHg, and straight esophageal
morphology without significant morphological changes distal to the
esophagus. Perforation is also one of the complications of LHM therapy
along with gastro-esophagal reflux which is also often experienced after
surgery.
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4. Per Oral Endoscopic Myotomy (POEM)

Endoscopic myotomy therapy is an alternative treatment for achalasia. In
short, through POEM therapy, a hole is formed in the submucosa layer to
reach the lower esophageal sphincter and also performs a dissection of the
muscle layer to reduce pressure on the lower esophageal sphincter. POEM
therapy has had a high success rate of 89-100%.
5. Pharmacological Therapy
The medical management of choice to be given to achalasia patients is
drugs that work by reducing the pressure of the lower esophageal
sphincter, especially using muscle relaxants. The two classes of drugs that
are most frequently and recognized as effective in the pharmacological
treatment of achalasia are nitrates and calcium channel blockers,
nifedipine in this case. Both drugs work by producing nitrogen oxides
followed by a decrease in intracellular calcium levels. Another
pharmacological agent that can also be used as a therapy for achalasia is
botulinum toxin, which is a neurotoxin. The benefit of this neurotoxin
itself is that it inhibits the release of acetylcholine from nerve endings.
This botulinum toxin is injected directly into the lower esophageal
sphincter by endoscopy. The disadvantages of this therapy are generally
that the effect of therapy does not last long, and it needs to be repeated to
respond well to the therapy given.
6. End-stage Acalacia Management
In end-stage achalasia, it is often characterized as megaesophagus or
sigmoid esophagus. It is characterized by large, rotating esophageal
dilation. In this final stage, esophageal resection therapy is needed to
improve quality of life. In some consensus it is stated that myotomy
therapy needs to be done first before doing esophageal resection. Once the
esophageal resection has been performed, reconstruction of the other
gastrointestinal tract is necessary, displacement of the stomach is the first
option in reconstructive therapy.
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G. Nursing Care Plans

Disorted Data Etiology Nursing Problems
DS : difficulty swallowing- nutrition less than
patients complain of achalasia, food stuck in needed
having difficulty the esophagus, reduced
swallowing both water absorption of nutrients,
and solid foods. less than required
Complaining like nutrients
burning chest before
eating or after eating.
DO : X-Ray, dilated
esophagus

Nursing Diagnosis
1. Nutritional imbalance less than requirement related to insufficient
nutritional intake, pain.
2. The risk of pain relates to difficulty swallowing

Diagnosis 1

Nutritional imbalance less than requirement related to insufficient nutritional

intake, pain.

a. Destination
After treatment, the problem of nutritional deficiencies can be overcome.
b. Result Criteria
• Nurses are able to improve the nutritional status of patients
• The nurse is able to control the patient's weight
• The patient is free from signs of malnutrition
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c. Intervention and Rational

NO Intervention Rational
1. Ask the patient if he or she has a To determine proper nutrition
history of food allergies. for the patient

2. Give support to the patient to get So that there is a balance

an adequate calorie intake between calorie needs and
according to body type and activity calorie intake
patterns
3. Patients are advised to eat slowly Eating slowly and chewing
and chew food thoroughly thoroughly can make it easier
for food to pass into the
stomach.
4. Feeding sparingly and frequently Improve digestion and prevent
with non-irritating ingredients

Diagnosis 2

The risk of pain relates to difficulty swallowing

a. Destination
After treatment acute pain can be relieved and reduced
b. Result Criteria
• Nurses are able to reduce pain levels, increase comfort levels and
control pain
• The patient is able to use a pain scale to identify his current level of
pain and determine his desired level of comfor
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c. Intervention and Rational

NO Intervention Rational
1. Ask the patient to report the The intensity, location and
location, intensity using the pain quality of pain should be
scale and pain quality. reported after the procedure
to determine the success of
the treatment.
2. Feeding little and often
Frequent and frequent
feeding is recommended
because too much food
overloads the stomach and
increases gastric reflux
3. Teach patients non- Used as a supplement to
pharmacological methods to
pharmacological methods
reduce client pain

4. Instruct the patient to use

Prevent drug abuse
analgesic drugs as recommended

Diagnosis 3

Changes in nutrition less than requirements associated with difficulty swallowing

a. Destination :

After nursing care for ... x 24 hours, there were no nutritional problems or
body weight returned to normal

b. Result Criteria:

• Weight gain in each target weekly.

• Reaching BB back before the illness.

• Increased appetite
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c. Interventions dan Rational

NO Intervention Rational

1. -Give food as needed Giving that is as indicated

and does not burden the
client if it is excessive

-Give food with small

portions but often Give food
not too dense and too liquid

-Prevent the occurrence of

food buildup in the
Esophageal

-Tell the client to always

finish his food
 CHAPTER 3

CONCLUDES

A. Conclusion

Conclusion Akatasia is a condition where the inferior esophageal sphincter

fails to relax during swallowing. As a result, food that is swallowed into the
esophagus fails to pass through the esophagus into the stomach. If achalasia
becomes severe, the esophagus often does not empty the swallowed food for
several hours, whereas the normal time is a few seconds. Over months and
years, the esophagus becomes an enlarged tube so that it can often hold as
much as a liter of food, which often becomes infected and rot during long
periods of esophageal static. Infection can also result in ulceration of the
esophageal mucosa, sometimes causing subternal pain or even rupture and
death. Acalacia can be treated by mechanically opening the valve, for example
by inflating a balloon in the esophagus. 40% of the results are satisfactory, but
may need to be repeated. By administering a nitrate (for example
nitroglycerin) which is placed under the tongue before eating or a calcium
channel blocker (for example nifedipine), the action to dilate the esophagus can
be suspended. As nurses we can provide Health Education to clients by
avoiding alcohol, and hot, cold and spicy foods and are encouraged to sleep
with our heads raised to avoid aspirations.

B. Suggestions

Papers are very far from perfect, therefore we as a group expect criticism
and suggestions from supervisors and fellow students. In addition, this
achalasia disease is very dangerous and we as hosts must be able to adopt a
healthy lifestyle so that our health is maintained.

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 BIBLIOGRAPHY

https://www.academia.edu/22510624/Makalah_akalasia

https://www.mayoclinic.org/diseases-conditions/achalasia/symptoms-causes/syc-
20352850

http://juke.kedokteran.unila.ac.id/index.php/medula/article/viewFile/2372/pdf

https://media.neliti.com/media/publications/67358-achalasia-a-review-of-
etiology-pathophys-aaac9865.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7005998/

https://www.mdpi.com/1422-0067/18/7/1399

https://www.alodokter.com/akalasia#:~:text=Komplikasi%20Akalasia,Kanker%2
0esofagus https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3386318/

https://www.alodokter.com/akalasia#:~:text=Komplikasi%20Akalasia,Kanker%2
0esofagus

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