Achalasia - Symptoms, Diagnosis and Treatment

Definition

The main elements are the LES hipertony, the lack of relaxation of LES with swallowing and the absence of the normal peristaltic in the 2/3 inferior esophagus. Practically there is on relaxation of LES during swallowing.

Etiopathogenesis (causes)

It is not well known:

• genetic factors
• environmental factors (neurotropic viruses)
• emotions
• stress

Clinical features

• dysphagia. Sometimes dysphagia may be paradoxal, with difficulties in liquid food intake but good tolerance of solid food.
• odynophagia  (painful swallowing)
• hiccup may occur lately, when the esophagus enlargement is important.
• the food and saliva regurgitation is quite frequent, appearing a few hours after meals, but in time, it decreases with enlargement. At  night, the regurgitation may lead to cough and dyspneea.
• In the final phases, the patient adopts typical position (Valsalva position),  by which  he/she increases the intrathoracic pressure thus making easier the passage of the alimentary bolus into the stomach.

Diagnosis

Endoscopy, X-ray and manometry can confirm the clinical diagnosis. 
Endoscopy will show a much-enlarged asophagus with alimentary rests and abundant saliva, but generally without mucosal lesions. The endoscopic pressure will allow a relatively easy passing into the stomach (differentiating the disease from an organic stenosis). The most important endoscopic element is to state the absence of neoplasia (gastric carcinoma).

Barium swallowing showing a much enlarged esophagus,which in its inferior region symmetrically narrows radish-like. The follow-up of swallowing reveals the absence of peristaltic of the asophageal body, as well as the lack of lower esophageal sphincter relaxation(it only opens under the burden of barium column).
 

Manometry. It shows the loss of peristaltic in the lower esophagus, the lack of LES relaxation during swallowing, and elevated basal lower esophageal sphincter pressure.

  

Differential diagnosis

• esophageal neoplasm; 
• organic esophageal stricture;
• diffuse esophageal spasm (nutcracker esophagus);
• achalasia;
• postcaustic esophageal stenosis.

Treatment

It is often difficult and consists in therapeutic alternatives:

1. Medical treatment with drugs that lower the pressure in LES, such as:

• nitrates
• nitrites
• calcium channel blockers (Nifedipine, Diltiazem)
• aminophylline
• anticholinergics.

One or two of these substances are used, being efficient in the initial phases of the disease.

2. Endoscopic – dilatation techniques of LES, by aid of spark plugs, balloons under fluoroscopic control. More modern is the endoscopic injection of botulinic inactivated anatoxin at LES level, realizing a temporary sphincterian muscular paralysis, with BoTox. The effect persists for a few months; later another injection may be repeated.

3. Surgical - when the techniques above mentioned are with no effects Heller LES cardiomiotomy is done(longitudinal section of circular fibers). Gastroesophageal reflux may follow successful treatment.