DISEASES OF THE OESOPHAGUS:2011

• I. ACHALASIA.
Achalasia is a primary
esophageal motility disorder characterized by:
- Failure of a hypertensive LES to relax
- Absence of esophageal peristalsis.
- => These abnormalities cause a functional
obstruction at the gastroesophageal junction.
 Pathophysiology

• LES pressure and relaxation are regulated by excitatory

(acetylcholine, substance P..) and inhibitory (nitric oxide,
vasoactive intestinal peptide…) neurotransmitters.
• Persons with achalasia lack nonadrenergic,
noncholinergic, inhibitory ganglion cells, causing an
imbalance in excitatory and inhibitory
neurotransmission.
• The result is a hypertensive nonrelaxed esophageal
sphincter.
• Etiology: Unknown.
 CLINICAL FEATURE:

Achalasia is characterized by the following

symptoms and signs :
• Dysphagia=difficult on swallowing (most
common)
• Regurgitation
• Chest pain
• Heartburn = pyrosis
• Weight loss
 DIFFERENTIAL DIAGNOSIS:  
-Stomach cancer .
-Cancer of the cardia: in the latter, the invasion of the esophageal
neural plexus by the tumor can cause nonrelaxation of the LES,
thus mimicking achalasia = malignant pseudoachalasia.
=>Since contrast radiography and endoscopy frequently fail to
differentiate these 2 entities, patients with a presumed
diagnosis of achalasia but who have a shorter duration of
symptoms, greater weight loss, and a more advanced age and
who are referred for minimally invasive surgery should undergo
additional imaging studies to rule out an occult
malignancy( transesophageal echography, Ct scan, Biopsy…).
 INVESTIGATIONS:

• Laboratory Studies
Laboratory studies are noncontributory.
• Imaging Studies
Barium swallow :
The esophagus appears dilated, and contrast
material passes slowly into the stomach as the LES
opens intermittently(>5sec.).
The distal esophagus is narrowed and has been
described as resembling a bird's beak .
 BARIUM SWALLOW:

BARIUM SWALLOW DEMONSTRATING THE BIRD-BEAK APPEARANCE OF THE LOWER ESOPHAGUS, DILATATION OF THE ESOPHAGUS, AND
STASIS OF BARIUM IN THE ESOPHAGUS.
 Esophageal manometry
• These findings include the following:
– Incomplete relaxation of the LES in response to
swallowing
– High resting LES pressure
– Absent esophageal peristalsis
Esophageal manometry
 Other investigations:
• Prolonged esophageal pH monitoring is
important for the following reasons:
– To rule out  GERD(
– To determine if abnormal reflux is being caused by
treatment
• Esophagogastroduodenoscopy (EGD) to rule out
cancer of the gastroesophageal junction or
fundus. If a tumor is suspected, perform
• Endoscopic ultrasound if a tomor is suspected.
 Medical Care

• Goal:
1.Relieve symptoms by eliminating the outflow resistance
2.Food bolus can travel through the aperistaltic body of the
esophagus by gravity.
I.Calcium channel blockers and nitrates decrease LES
pressure:
Nifedipine S/ 20-30mg BD
Isosorbide dinitrate S/ 5-10mg daily
Approximately 10% of patients benefit from this
treatment.
 Medical care…
II.Endoscopic intrasphincteric injection of botulinum toxin to block the
release of acetylcholine at the level of the LES.
Only 30% of patients treated endoscopically still have relief of dysphagia
1 year after treatment.
This treatment can cause an inflammatory reaction at the level of the
gastroesophageal junction, making a subsequent myotomy very difficult.
III.Pneumatic dilatation is the recommended treatment in those sporadic
cases in which surgery is not appropriate.
A balloon is inflated at the level of the gastroesophageal junction to
blindly rupture the muscle fibers while leaving the mucosa intact.
The success rate is 70-80%, and the perforation rate is approximately 5%.
 Surgical Care

• Laparoscopic Heller myotomy and partial

fundoplication has excellent results, a short
hospital stay, and a fast recovery time.