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04-21-2008, 10:52 AM
¦Definition:
Neuromuscular incoordination of the lower end of the oesophagus which leads to failure of relaxation of the cardia and impaired peristalsis of the body of the oesophagus.
¦Aetiology: (Many theories)
Nerve dysfunction theory: Deficiency of Auerbach’s nerve plexus in lower oesophagous vagal pathway.
Hormonal : Increasesensitivity to gastrin hormone.
Other theories: ·Neurotoxic virus.
· Autoimmune process.
· Vitamin deficiency.
¦Cl. Picture:
v Common in psychoneurotic young age individuals.
v Dysphagia which is of intermittent course, of long duration, and more to fluids than solids. WHY? because solid food dilate the cardia by its weight. Swallowing may be helped by drinking fluids or employing some positions or actions (e.g. Valsalva manoeuvre).
v In some patients cold liquids cause symptoms more frequently than warm liquids.
v Regurgitation described by the patient as vomiting.
v Sensation of retrosternal fullness.
v Halitosis (bad breath) and persistent eructation of foul air are common and sometimes they are the only complaint.
v Cough, wheezing and chocking sensations are due to aspiration.
v Sometimes pneumonia and lung abscess are the first signs of achalasia, and patients may die of acute or chronic lung disease.
v The general condition of the patient is maintained for a long time, but advanced achalasia with massive dilatation is usually associated with weight loss and anemia
¦Complications:
(1) Esophagitis and ulceration.
(2) Monilial infection spontaneously or induced by antibiotic therapy.
(3) Leukoplakia and malignant change in 3% of cases.
¦Differential diagnosis:
From different causes of oesophageal obstruction especially the following:
(1) Sclerodemia, (associated Raynaud’s phenomenon.)
(2) Carcinoma, older patient, shorter duration, progressive dysphagia, emaciation, barium swallow shows a high obstruction with irregulr rat tail stricture and esophagus is not markedly dilated. Esophagoscopy (and biopsy) is diagnostic.
(3) Reflux esophagitis with stricture formation. Diet dependant obstruction rather than the constant obstruction with achalasia.
(4) Chagas disease: identical to achalasia and is managed in the same way.
¦Diagnosis:
1) Plain X-ray erect position: Mediastinal shadow due to dilated oesophagus with air fluid level. No gastric air bubble.
2) Barium swallow: Marked oesophageal dilatation with smooth tapering lower end.{Hen's (Parrot's) peak}{Cigar shaped oesophagus}. In advanced cases the esophagus may also elongate and assume a sigmoid shape.
3) Radio-isotope transit: To detect retention of the isotope within the oesophagus. It is non invasive test to monitor the results of treatment by drugs or dilatation.
4) Oesophagoscopy: To exclude organic lesion.
5) Oesophageal Manometry (Oesophageal Motility Studies): Absence of tone in wall with high pressure in the sphincter.
· The normal pressure at the gastro-oesophageal junction is 30 cm water by open-tip tube method and higher by balloon method.
¦ Treatment:
1) Medical: Psychotherapy & antispasmodics in early cases.
2)Dilatation:By mercury loaded bougies or hydrostatic bags But more dangerous than surgery why? (Rupture of the circular muscle with balloon overinflation may cause rupture of the mucosa).
Technique: Nowadays, the preferred method of dilatation for achalasia is by the pneumatic technique with Hurts dilators and more recently the Rigiflex dilator which has a pressure gauge (similar to the angioplasty catheter). Maximum inflation needs great experience and depends on the resistance of the constricting sphincter.


3) Surgical Treatment:
" Cardiomyotomy" (Heller's operation):
In which muscle coat is divided longitudinally until mucosa bulges. It can be done through the abdominal, thoracic or thoracoabdominal approach.
3 cm cardiomyotomy may be effective and needs no antireflux measure.
7 cm cardiomyotomy is more effective but antireflux measure is
necessary.
Laparoscopic or thoracoscopic cardiomyotomy can be done and has the advantages of endoscopic surgery:
1-Minimal surgical wounds.
2-Low postoperative morbidity.
3-Short hospital stay minimize costs which may equal the slight expensive cost of endoscopic surgery.
SOURCE: DR. AYMAN SALEM'S BOOK
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