AchalasiaThe ABCs of

UNDERSTANDING THE FACTS BEH IND

A primary motility disorder of the oesophagus caused by failure of thelower oesophageal sphincter (LOS) to relax and progressive failure ofcontraction of the oesophageal smooth muscle. The pathophysiology of the condition is poorly understood but it isthought to be caused by progressive destruction of the ganglion cellsof the myenteric plexus

1. Definition

CREDITSContent- Joanne Thong Yuen Heng; Design - Chia Yen Lek (SIGMUM 2021/2022)

Urgent endoscopy Esophageal manometry→ gold standard for diagnosis of motilitydisordersBarium swallow→ rarely performed but show proximal dilation of theoesophagus with characteristic “bird's beak” appearancekey features of achalasia on manometry

Absence of oesophageal peristalsisFailure of the LOS to relaxIncreased resting tone of the LOS

Note: In all patients with dysphagia oesophageal cancer must be ruledout.

4. Investigations

Conservative Sleeping with many pillows

To minimise or avoid regurgitation and nocturnal coughEating food slowly and chewing thoroughlyPlenty of fluids with mealsCalcium channel blockers or Nitrates can prevent temporary reliefBotox injections

Injected into the lower oesophagus→ effective for a fewmonths

SurgicalEndoscopic balloon dilation

Insertion of a balloon into the LOS & dilated to stretch musclefibresGood response in 75% of patients but there is a risk ofperforation5% need further intervention

Laparoscopic Heller myotomyDivision of specific fibres of the LOS which fail to relaxLong-term improvement seen in 85% of patients

Peroral Endoscopic Myotomy (POEM)Relatively new procedureA flexible endoscope is passed into the oesophagus and usedto make a small incision in the oesophageal mucosaThe endoscope is then tunneled into the oesophageal wall andmuscle fibres that fail to relax are divided

5. Management

Diffuse oesophageal spasmSystemic sclerosisGORDOesophageal malignancyAngina pectoris

3. Differential diagnosis

Progressive dysphagia→ both solids and liquidsVomiting/ food regurgitationNocturnal cough (due to overspill aspiration)Chest discomfort/painHeartburn Weight loss

2. Clinical features

CREDITSContent- Mufaro Mutoti; Design - Chia Yen Lek (SIGMUM 2021/2022)