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.
Scar tissue built over time in the esophagus can lead to an esophageal stricture. The scarring can be due to acid irritation. Persons suffering from GERD might be more prone to chronic esophageal strictures. Gastric build-up in the stomach can reflux into the esophagus. Gradually it leads to esophagus stricture due to damaged lining. It can manifest as a ring around the esophagal opening. These are usually benign. In rare cases, injuries caused by an endoscope or nasogastric tube might cause scarring leading to a stricture in the esophagus. This might also result in those who have swallowed battery acid or household cleaners.
Symptoms of esophagal stricture
Barium meal test or endoscopy helps detect narrowing of the esophagus. Chronic esophageal stricture is often treated with dilation. In extreme cases, surgery is resorted to.
An esophageal ulcer also occurs due to bacterium H. pylori. But they are largely seen in persons who suffer GERD - GastroEsophageal Reflux Disease . When the contents of the stomach are pushed back into the esophagus and throat because the diaphragm in unable to prevent the backlash. Alcohol abuse, smoking and excessive aspirin or ibuprofen use are common causes for formation of Esophagitis-Peptic Ulcer.Pain is felt in the region above the navel and is worse when the stomach is empty. Other symptoms include blood in vomit, appetite changes, nausea and dark tarry stools. HPV, HSV and candida infection can lead to esophageal ulcers. Esophageal ulcers are usually treated with antibiotics. Acid reducers are also prescribed. Medications to reduce acid production help in protecting the stomach lining. Eating the right foods that do not provoke acid production in the stomach helps tackle ulcers.
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Bibliography / Reference
Collection of Pages - Last revised Date: July 15, 2019