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.
Esophagram is a test whereby the patient is administered a barium sulfate compound that enables the radiologist to study the function and appearance of the esophagus. A series of x rays of the esophagus is taken after the patient has swallowed the barium. The barium solution coats and outlines the walls of the esophagus. This enables the radiologist to assess the process of swallowing. Hence it is also called barium swallow. An Esophagram is done when the patient complains of pain or difficulty in swallowing. It is also done to assess the reasons for blood stained vomit and when abdominal pain and weight loss occurs or diagnosing cases of Barrett's esophagus. The Esophagram helps the radiologist to detect narrowing, stricture, obstruction or irritation of the esophagus. It helps to study complications such as ulcers, polyps and tumors. It also helps to assess hiatal hernia.
The patient is advised not to eat or drink for 8 to 10 hours prior to the examination. The patient is asked not to smoke or chew gum at least 6 hours prior to the procedure. A patient is given a cup of barium sulfate to swallow. A radiologist watches and evaluates the swallowing process with fluoroscopy. The barium swallowed coats the lining of the esophagus, and x rays are taken to track the pathway to the stomach. The patient is placed in various positions throughout the exam so that structures are optimally demonstrated on the x rays.
The problem is that it can miss small abnormalities in the esophagus such as small erosions and ulcers. This test is not very effective for diagnosing gastro esophageal reflux associated with GERD. Pregnant mothers are advised not to undergo this procedure as the risk of radiation affects the fetus.
Esophagitis is a condition where there is inflammation and swelling of the esophagus. Esophagitis is caused by stomach acid reflux, fungal or viral infection of the esophagus, certain medications and weakened immune system. If esophagitis is left untreated, it can lead to ulcers and difficulty in swallowing. This can lead to scarring of the esophagus and a situation where food may stick in the area (dysphagia). Often Hiatus Hernia causes Esophagitis since the distension of the stomach through the diaphragm muscle hampers the draining of food and stomach acid. This results in the damage of the esophageal tissue. Candida yeast infection can develop in the esophagus and lead to esophagitis. It attacks when the immune system is weakened and is treated with anti-fungal drugs.
A person suffering from esophagitis has difficulty in swallowing and nausea and vomiting. There are mouth sores. Heartburn involves acid reflux into the esophagus as a burning sensation with a bitter-tasting liquid that may regurgitate into the mouth. A patient can reduce the symptoms of esophagitis by eating smaller meals and avoiding eating for 2 hours before going to bed. Avoid too much spices and acidic food and beverages. Take small bites and chew food thoroughly before swallowing. Place your head at an elevation while sleeping to prevent regurgitation and stomach acid reflux. Smoking, alcohol, caffeine, chocolate, peppermint and fatty foods can aggravate the condition.
The physician can view the esophagus with an endoscope to look for scarring and inflammation. A biopsy can be taken for diagnosis. A Barium swallow involves use of a special dye to facilitate x-ray of the esophagus and check for abnormalities. Antacids can help in reducing stomach acid reflux. Medication to improve the strength of the LES muscle can help in treating esophagitis. Antibiotics or anti-fungal drugs may be prescribed to treat the infection. Inflammation can be reduced with the help of Corticosteroid medication. Surgery is resorted to in cases where there is a hiatus hernia or to remove the damaged part of the esophagus.
Bibliography / Reference
Collection of Pages - Last revised Date: March 21, 2019