Achalasia Cardia
ACHALASIA CARDIA
- It is a primary oesophageal motility disorder.
- Also called as cardiospasm.
- Oesophagus undergoes non peristaltic contractions.
Etiopathogenesis-
- Idiopathic- it is due to absence or degeneration of Auerbach’s plexuses leads to primary achalasia.
- Acquired- associated with Chaga’s disease, Trypanosoma cruzi (sleeping sickness)
- Stress and emotional factors.
Clinical features-
- Females : males- 3: 2 ratio
- Classic triad- Dysphagia, regurgitation, weight loss
- Anaemia
- Retrosternal discomfort
- Pseudoachalasia- tumours of cardia mimicking achalasia cardia. It is produced by adenocarcinoma achalasia.
Investigations-
- Plain X-ray abdomen- absence of gastric air bubble
- Barium swallow- shows cucumber oesophagus or birds beak or pencil tip deformity.
- Sigmoid oesophagus
- Chest X- ray shows pseudotumour mass
- Retro cardiac air fluid level is seen in lateral view.
5. Oesophagoscopy-
- Dilated sac
- LOS has rosette appearance
6. Oesophageal manometry-
- Characteristics of achalasia cardia
- Hypertensive LOS
- Aperistalsis in the body of oesophagus
Treatment-
- Modified laparoscopic Helle’s cardiomyopathy is the choice of surgery
- Injection Botulinum toxin- LOS endoscopically
- Drugs- sublingual nifedipine
- Endoscopic myotomy
Exam Important
- Mode of treatment for achalasia is associated with high rate of recurrence : Botulinum toxin.
- Progressive Dysphagia,Regurgitant vomitting is a presenting problem.
- Dilated and Tortuous Esophagus is seen in Achalasia Cardia.
- The cause is degeneration of ganglion cells of auerbach’s myenteric plexus.
- Treatment includes heller’s cardiomyotomy, forceful dilation by pneumatic balloon, repeated injection botulinum toxins and drugs improving motility of esophagus.
- Esophagectomy is not a treatment modality for achalasia cardia.
- Barium swallow shows a dilated esophagus with tapering narrowing in the terminal end of esophagus, described as ‘BIRD BEAK’ appearance.
- Fluoroscopy shows loss of normal peristalsis in the lower third of the esophagus..
- Dysphagia equal for both solid and liquid from the very onset suggests motor disorder i.e achalasia and diffuse esophageal spasm.
- The characteristic esophageal manometry finding in achalasia cardia is Impaired lower esophageal sphincter relaxation and absent peristalsis.
- It is believed that cause of ganglion cell degeneration in achalasia is an autoimmune process attributable to a latent infection with human herpes simplex virus 1 combined with genetic susceptibility.
- The malignancy which is a close mimicker of achalasia is Carcinoma of gastric fundus.
- The most sensitive diagnostic evaluation for achalasia cardia is Esophageal Manometry.
The pharmacologic agents used in Achalasia are:
- Nitrates
- Calcium channel blockers
- Botulinum toxin
- Sildenafil- phosphodiesterase inhibitors, effectively decrease LES pressure.
- In pneumatic dilatation for the treatment of achalasia, the cylindrical balloon dilator is dilated upto 3-4 cm.
- Achalasia is associated with increased risk of Squamous Cell carcinoma of Esophagus.
- Uniform dilation of esophagus is seen in Achalasia Cardia.
- Elevated resting LES tone is seen in Achalasia.
- A 40-year-old female patient presented with dysphagia to both liquids and solids and regurgitation for 3 months. The dysphagia was non-progressive.Achalasia cardia is the most likely diagnosis.
- ‘Pencil tip’ deformity is seen in Achalasia Cardia.
- Heller’s operation treatment of choice in Achalasia Cardia.
- Radiologic feature suggestive of Achalasia cardia is- Absence of gastric air bubble , Air fluid level in mediastinum ,Sigmoid esophagus.
- Maximum dilatation of esophagus occurs in Achalasia Cardia.
- Amyl nitrite inhalation is used to distinguish patients of achalasia from those with pseudoachalasia.
- Non visualization of gastric fundic bubble with air-fluid level in retrocardiac region suggests Achalasia Cardia.
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