What is Achalasia

Achalasia is a disorder of the tube that connects your mouth and stomach (esophagus). This disorder makes it difficult for your esophagus to move liquids and food into your stomach.

This makes it harder for you to swallow. Achalasia also affects the muscle between your stomach and your esophagus (lower esophageal sphincter,LES). Normally, this muscle relaxes after you swallow. With achalasia, it does not relax, and there is increased pressure in this area.

What are the classic findings of esophageal achalasia? 

Achalasia is a primary motility disorder of the esophagus characterized by a loss of enteric neurons leading to absence of peristaltic waveform in the body and impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing. The condition is relatively rare, occurring at an incidence of 0.5 to 1 per 100,000 of the population per year, yet it is the most commonly diagnosed primary esophageal motility disorder. Peak incidence is between 20 and 50 years of age, and it typically has an insidious onset.

What are the causes?

The cause is not known.

What increases the risk?

Risk factors may include:

  • Age. Achalasia is more common in older adults.
  • Family history of achalasia.

What are the symptoms?

Signs and symptoms of achalasia may include:

  • Difficulty swallowing or painful swallowing.
  • Weight loss.
  • Chest pain.
  • Coughing or wheezing.
  • Heartburn.
  • Burping.
  • Vomiting.
  • Bad breath (halitosis).

Most common symptoms

The nonrelaxing LES causes a functional outflow obstruction to the lower esophagus, resulting in progressive dysphagia, regurgitation, weight loss, and chest pain.

How is this diagnosed?

Achalasia may be diagnosed by:

  • X-ray.
  • Endoscopy. This is when your health care provider looks at your esophagus with a small flexible tube that has a video camera at the end.
  • Studies to see if there is increased pressure in your LES.

How is this treated?

There is no cure for achalasia. Treatment is directed at managing your symptoms. Treatment may include:

  • Medicines.
  • Stretching or dilating your LES.
  • Surgery to reduce pressure in your LES.

What are the nonsurgical options for treatment of achalasia?

• Smooth muscle relaxants (nitrates, calcium channel blockers)

• Botulinum toxin

• Pneumatic dilatation of the LES

How do long term results of Heller myotomy compare with mechanical esophageal dilatation? 

On the basis of excellent results with laparoscopic Heller myotomy, it is largely considered the optimal treatment for severe symptoms of achalasia.

Several large retrospective series have compared the two treatments and favor operative myotomy over pneumatic dilatation.

With the introduction of the minimally invasive approach, the historical concerns about the morbidity associated with open surgical techniques have essentially disappeared and the morbidity and mortality of both surgical and nonsurgical options are now nearly identical.

The long-term success and safety of laparoscopic myotomy have completed the shift in favor of surgery as the primary therapeutic option for patients with achalasia. 

However, a recent randomized controlled trial that compared laparoscopic Heller myotomy (with Dor fundoplication added) with pneumatic dilatation revealed that the two techniques are equally effective in a 2-year follow up.

Treatment algorithm for patients with achalasia

In summary, the treatment options for achalasia are initially medical (nitrates, calcium channel blockers), botulinum toxin injection, and pneumatic dilation. Surgical treatment (laparoscopic Heller myotomy, with Dor fundoplication) is reserved for patients with severe symptoms. 

Patients who are unwilling to undergo any procedure should be treated with medications. Botulinum toxin injection should be reserved for patients who are unable to tolerate surgery because of significant comorbidities, or patients whose clinical presentation is complicated, putting the diagnosis of achalasia in doubt. 

Overall, younger patients may choose early surgical intervention to avoid the need for multiple pneumatic dilatations. The decision for either of these two approaches will eventually be based on the medical specialist’s experience and the patient’s preference. Peroral endoscopic myotomy has also been gaining popularity as a means of treating achalasia.

Follow these instructions at home:

  • Take medicines only as directed by your health care provider.
  • Do not eat or drink while lying down.
  • Do not drink hot or cold liquids.
  • Eat your food slowly.
  • Keep all follow-up visits as directed by your health care provider. This is important.

Contact a health care provider if:

  • Your symptoms don’t go away after treatment.
  • You have a fever.
  • You have any new symptoms.
  • Your pain is worse.

Get help right away if:

  • You vomit blood.
  • Your have chest pain.
  • You have difficulty breathing.

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