WAHEED NOOR.

TOPIC: ACHALASIA AND OESOPGAGIAL

Achalasia
CANCER.
 Achalasia
• Achalasia is a motility disorder of the
esophagus characterized by absence of
peristalsis and failure of relaxation of lower
esophageal sphincter.
This causes obstruction at level of esophago-
gastric junction.
 Achalasia
• The term achalasia means "failure to relax" and refers to
the inability of the lower esophageal to open and let food
pass into the stomach. As a result, patients with achalasia
have difficulty in swallowing food.
• It  also known as esophageal achalasia, cardiospasm,
and esophageal aperistalsis, is an esophageal motility
disorder involving the smooth muscle layer of
the esophagus and the lower esophageal sphincter (LES). It
is characterized by incomplete LES relaxation, increased
LES tone, and lack of peristalsis of the esophagus (inability
of smooth muscle to move food down the esophagus).
 Etiology
• The cause of achalasia, is unknown. Recent studies show
achalasia is caused by nerve cells of the involuntary
nervous system within the muscle layers of the
esophagus. They are attacked by the patient’s own
immune system and slowly degenerate for reasons that
are not currently understood.
• However, a small proportion occurs secondary to other
conditions, such as esophageal cancer or Chagas
disease (an infectious disease common in South America).
Achalasia affects about one person in 100,000 per year.
 Histopathology of achalasia
• Histologic examination shows a decrease in
the neurons of the myenteric plexuses.
• There is a preferential decrease in the nitric
oxide producing cells. These contribute to LES relaxation
• There is a relative sparing of the cholinergic
neurons which is responsible for maintaining LES tone
• The loss of these inhibitory neurons leads to
an increased resting tone in the LES.It also leads to
aperistalsis of the esophagus
 Pathophysiology
• Achalasia results from the degeneration of neurons in
the esophageal wall.
• Histological examination reveals decreased numbers of
neurons (ganglion cells) in the myenteric plexuses, and
the ganglion cells that remain often are surrounded by
lymphocytes and, less prominently, by eosinophils.
• This inflammatory degeneration specially involves the
nitric oxide-producing, inhibitory neurons that effect the
relaxation of esophageal smooth muscle.
 Signs and symptoms
The main symptoms of achalasia are 
• Dysphagia (difficulty in swallowing) 
• Regurgitation of undigested food 
• chest pain behind the sternum,
• Weight loss. 
• Coughing when lying in a horizontal position.
• Aspiration.
 Diagnosis
o Three tests are most commonly used to diagnose and
evaluate a swallowing problem:
• Barium swallow. The patient swallows a barium
preparation (liquid or other form) and its movement
through the esophagus is evaluated using X-ray.
• Endoscopy. A flexible, narrow tube called an endoscope is
passed into the esophagus and projects images of the inside
of the esophagus onto a screen.
• Manometry. This test measures the timing and strength of
esophageal contractions and lower esophageal sphincter
(valve) relaxation.
 Treatment
• The approach to treatment is to reduce the pressure at the
lower esophageal sphincter. Therapy may involve:
• Injection with botulinum toxin (Botox). This may help relax
the sphincter muscles.
• Medications, such as long-acting nitrates or calcium
channel blockers, which can be used to relax the lower
esophagus sphincter
• Surgery (called an esophagomyotomy), which may be
needed to decrease the pressure in the lower sphincter
• Widening (dilation) of the esophagus at the location of the
narrowing.
 Complication of achalasia
o The complications of Achalasia include:
• Weight Loss
• Pneumonia
• Esophagitis
• Esophageal Cancer
• Achalasia can give rise to many complications if it is not
treated in time. These complications may include Back flow
of food and Acid in to the Esophagus. If the food items enter
in to the Lungs, it can be a cause of Pneumonia. Sometimes
a tear may occur in the Esophagus too.
 Nursing diagnosis
• Dysphagia (difficulty in swallowing) related to
aperistalsis.
• Backflow of food related to narrowing of esophageal
hiatus.
• Heart burn related to reflux of food.
• Pain related to spasm of the esophageal muscle.
• Anxiety and stress related to disease.
Nursing interventions of achalasia
• The nurse works with the patient and family to explore
diet and lifestyle modifications that will best control
dysphagia, which is prominent in achalasia.
• Education begins with careful assessment of the scope
of dysphagia, which includes the following:
o Swallowing ability with liquids v/s solids.
o Response to foods of different textures and
temperature.
o Variability of the dysphagia.
o Response to stress, fatigue and other activities.
o Approaches used by the patient to manage the
dysphagia and the degree of success.
 Cont….
• Give antacid to relieve from heart burn.
• Give analgesics to relieve from pain.
• Encourage the patient and provide emotional
support.
 References
• Orlando RC. Diseases of the esophagus. In: Goldman
L, Ausiello DA, eds. Cecil Medicine. 23rd ed.
Philadelphia, Pa: Saunders Elsevier; 2007:chap 140.
• Essential of medical surgical nursing by BT
Basavanthappa.