Achalasia

Achalasia is a disorder that causes problems in the esophagus or first area of the GI tract, the swallowing tube. Because of a failure of the lower esophageal muscle to relax, food becomes lodged in the lower esophagus and food does not move through to the stomach. The disease also is consistent with not only a failure of the muscle to relax, but a failure of the esophagus to push food into the stomach. This failure of esophageal muscle motility is called aperistalsis. The combination of both esophageal problems causes difficulty swallowing: liquids and solids. Other symptoms include chest pain, heartburn, difficulty belching, a sensation of a lump in the throat, hiccups, and weight loss.

The cause of achalasia is not known, but this disease tends to worsen over a period of years. It is seen in 20-50 year olds, and many patients delay medical treatment until the symptoms become unbearable.

People with achalasia often have food stuck in the esophagus. Food finally passes into the stomach after the pressure from the food in the lower esophagus overpowers the tight lower esophageal sphincter and propels the food onward.

Diagnosis
A barium swallow is a screening test for achalasia. The patient drinks barium, which is a liquid that outlines the esophagus when an X-Ray is taken. If a patient has achalasia, the barium gets stuck at the bottom of the esophagus. This failure of barium to move into the stomach often resembles a bird's beak.If barium fails to move into the stomach, a patient undergoes a manometry test of the esophagus.

Manometry is the study of pressure within the esophagus. A pressure probe is placed in the esophagus, and muscle waves are measured to determine if aperistalsis exists. With a bird's beak pattern on barium swallow and aperstalsis on manometry, achalasia is diagnosed, and treatment options can be entertained.

Before achalasia can be diagnosed, however, an EGD (esophagogastroduodenoscopy) is performed. By using a thin tube with a camera on the end, the esophagus and stomach can be examined. This test is necessary to rule out condidtions that shadow achalasia. Conditions such as esophageal ulcers or esophageal cancer can mimic symptoms of achalasia, and these need to be ruled out before treatment options for achalasia can be discussed.

Treatment options for Achalasia

Medical therapy: two classes of drugs called calcium channel blockers and nitrates are the first mode of treatment for this condition. These drugs relax the muscle at the bottom of the esophagus and allow the passage of food. These drugs may have side effects such as low blood pressure, dizziness, and headaches; and these drugs tend to wear off over time, so there use is limited in the treatment of achalasia.

Pneumatic dilation: This therapeutic intervention allows for the passage of a balloon across the muscle at the bottom of the esophagus. The balloon is inflated and the muscle is stretched. This intervention relieves symptoms in many people, but it needs to be repeated multiple times during multiple sessions to achieve adequate therapeutic results. This procedure also carries risks, the most serious being the tearing of the esophagus in 3%. If a tear occurs a patient may have to have major surgery to sew the torn esophageal muscle. If after multiple dilation attempts, a patient remains symptomatic from the achalasia, the gastroenterologist usually recommends surgical referral.

Botulinum toxin injection: this relatively new  procedure can be used also. During EGD, a small needle is passed through a hollow channel of the scope and botulinum toxin is injected near the muscles at the lower end of the esophagus. Botulinum toxin is a medication which poisons the nerves causing contraction of the muscles. The muscle fibers relax after poisoning. This treatment is successful in 50-60% of patients, but its effects may be short lived and repeat treatment with this toxin is usually necessary.

Heller Myotomy: This surgical procedure involves the cutting of the muscle fibers at the lower end of the esophagus. This procedure requires that a tiny camera be placed in the chest cavity. This camera allows the esophagus to be seen, allowing the surgical disruption of the bottom of the esophagus.  This is the most invasive treatment but offers the patient long term relief from symptoms. 80% of patients are symptom free for 10 yrs after undergoing Heller Myotomy.