Achalasia is a neurological disorder of the esophagus and the muscles associated with it. Achalasia is a Greek term which means lack of relaxation. It involves the sphincter muscles of the esophageal region which help in the movement of food in the alimentary by esophageal peristalsis. The upper esophageal sphincter muscle measures about 3- 4 cm and is composed of striated muscles. The lower or the distal esophageal sphincter muscle is smooth. The esophagus is further comprised of circular and longitudinal muscles which help in the peristaltic movement. The muscles of the mesenteric plexus have a significant role in the occurrence of conditions such as achalasia. This is because of the association of the mesenteric plexus with intramural nerve innervations. Studies reveal that the damage of the mesenteric plexus is caused by the immune system.
Clinical manifestations of Achalasia
Classical symptoms associated with achalasia include dysphagia, regurgitation and respiratory complications. The lower esophageal sphincter muscles are impaired in this condition causing distended lower esophagus. In this region, the food is stuck as the muscles of the lower esophageal sphincter do not relax causing disturbance in the peristaltic movements of the esophagus. The patient experiences pain or spasms as a result of the cramped food in the esophagus. Often there is a tendency to vomit followed by heartburn and weakness.
Incidences of chest pain and breathing difficulties due to nocturnal choking are not uncommon. Histological examination of the esophagus reveals the decrease in myenteric neurons which are predominantly responsible for the relaxation of the lower esophageal sphincter muscles. Achalasia is categorized as primary, secondary and pseudoachlasia depending upon the etiology of the disease. The primary cause of achalasia can be hereditary or underlying autoimmune disease. The secondary cause is associated with preexisting infections such as chagas disease. It is usually associated with malignancy.
Diagnosis of Achalasia
Achalasia onset is generally asymptomatic and the severity increases after five years. Patients who are probable suspects of achalasia are diagnosed using radiologic, manometric and endoscopic methods. The manometric analysis determines the esophageal pressure of the lower origin. This enables the peristalsis and relaxation associated with the esophagus. It also indicates the functionality of smooth muscle contraction pertaining to the lower esophageal region. Radiological analysis indicates the abnormalities in structural arrangement of the esophagus. The bird beak appearance of the esophagus is the classical sign for the occurrence of achalasia. A normal chest X-ray does not identify the presence of achalasia, but it gives an anatomical description of the respective changes pertaining to esophagus such as widening of the mediastinum due to esophageal dilation and presence of gastric air bubble which occurs because of lack of relaxation in the lower esophagus.
Treatment of Achalasia
The restoration of the esophagus is difficult. However, many treatment options are available for achalasia. Use of nitrates and calcium blocking drugs help in the prevention of calcification of the esophagus. In some cases, balloon dilation of the lower esophagus is done. Although this method has a short time recovery there is always a risk of perforation during the procedure. Surgical methods such as thoracotomy and myotomy are considered. In addition to these treatment options, endoscopic administration of botulinum toxin has also become a possible option.
Barium Swallow or Upper GI series is a radiological test that allows visual examination of the esophagus, stomach, duodenum and small intestine. Nothing should be eaten for about 6 hours prior to the test. Typically, double contrast barium swallow is used. The patient is made to swallow a barium drink after swallowing an effervescent agent. The barium creates a temporary coating on the lining of the upper GI tract. Then he is asked to stand and lie in different positions to spread the liquid. An x-ray machine then takes pictures. Fluoroscopy is often used during a barium swallow.
After this test, patients are asked to drink extra fluids and water to relieve the bowels of the barium. Constipation or fecal impaction may occur if the barium isn't completely eliminated from the body. This diagnostic test is used for detecting dysphagia, hernia, peptic ulcer disease, GERD (Gastro Esophageal Reflux Disease), achalasia, generalized epigastric pain and suspected perforation.
Barium Swallow Test
Barium sulfate is a popular compound used in the diagnostic investigation of abnormalities of internal organs. This test is used to investigate issues of upper gastrointestinal tract. Most cases in this diagnostic category include abnormalities associated with esophagus and the digestive system. Barium swallowing procedure determines the presence of anatomical abnormalities such as narrowing of the esophagus, abnormal growths such as cancer, tumors, polyps and also for the presence of foreign objects as a result of ingestion. Barium swallow test also helps in the identification of conditions such as hiatal hernia. In this condition, the upper portion of the stomach protrudes into the chest cavity through the diaphragm opening called esophageal hiatus.
Preparation for Barium swallow test
Since barium swallow is a radiological procedure, patients are usually advised not to take any food the night before the test. This enables the radiologist to analyze and discover underlying abnormalities in the gastro intestinal tract. Presence of food particles can mask the diagnosis to a great extent. The radiologist may make general enquiry to ensure that the patient is not pregnant or on insulin. Before the test is performed, the patient is advised to drink a milky liquid. This liquid contains barium sulfate. Many patients complain about the chalky taste of this liquid.
In some cases, it induces nausea. In addition to the barium sulfate liquid, the patient is also advised to take few pills that produce bubbles or effervescence. The effervescence induced by the pills is necessary to facilitate the air in to the stomach to view the structures carefully. Patients are advised not to belch although the procedure induces it. This enables the radiologist to identify the underlying disorders better. The risks associated with barium swallow test are minimal. One of the most common side effects of this test is constipation. Other conditions include anaphylactic reactions and aspiration in which the ingested barium enters the windpipe. The entire procedure may last around 30 minutes. Fluoroscopy is often used during a barium swallow.
Barium enema is advised for patients who experience difficulties in bowel movements and also associated conditions such as weight loss and anemia. Barium sulfate is administered through the anus by using a tube to investigate the bowel disorders in the patient. This radiological examination gives a complete picture of the bowel beginning from the colon to the large intestine. Abnormalities such as colon cancer, polyps, peptic ulcer disease, GERD (Gastro Esophageal Reflux Disease), achalasia, strictures and tumors can be identified with this method. Drugs such as buscopan are given to the patients to relax the bowel.
Patients are advised not consume any solid foods or milk products as it may hinder the diagnosis. The recommended diet for the patients undergoing this test is usually clear fluids and juices. Although the test has minimal side effects, many patients experience the inconvenience of cramping during the procedure. The intensity of cramping varies from person to person. Bowel relaxation drugs are administered to prevent unprecedented events during the procedure. During the procedure, patients often experience the urge to defecate which has to be controlled in order to obtain proper diagnosis of the bowel. One of the significant risk factors associated with this procedure is the leakage of barium from previously perforated colon. The side effects of the leaking barium from the colon can be fatal. Hence, thorough preparation is done before the test to ensure and minimize the risk factors. Pregnant women are not advised to do this procedure. After this test, patients are asked to drink extra fluids and water to relieve the bowels of the barium.
Bibliography / Reference
Collection of Pages - Last revised Date: February 17, 2019