Achalasia

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Background

  • Inability of LES to relax and loss of normal peristalsis [1]

Clinical Features

  • Dysphagia
  • Regurgitation
  • Chest pain
    • Esophageal spasm can feel like tight, crushing retrosternal pain similar to ACS

Differential Diagnosis

  • Ingested foreign body
  • Esophageal carcinoma - dysphagia predominantly for solid foods during initial stages
  • Reflux esophagitis - dysphagia results from inflammatory swelling or a fibrotic stricture
  • Pseudoachalasia - underlying malignancy mimics achalasia
  • Connective tissue disorders - e.g. systemic sclerosis
  • Esophageal spasm - chest pain a predominant feature

Evaluation

  • Upper GI
    • Esophageal dilatation
    • Birds beak sign
Barrium swallow showing birds beak appearance
  • Esophageal Manometry
Aperistaltic contractions, increased intraesophageal pressure, and failure of relaxation of the lower esophageal sphincter.

Management

  • Trial of antispasmodic for Esophageal Spasm
    • Nifedipine
  • Surgical intervention
    • Baloon dilatation
    • Botulinum toxin injection [2]
    • Myomectomy
    • Consider gastrostomy for frail and older patients
  • Patients need to eat upright at all times.
  • Treatment may improve dysphagia, but there is no cure and swallowing never completely normalizes

Disposition

See Also

External Links

References

  1. Krill JT, Naik RD, Vaezi MF. Clinical management of achalasia: current state of the art. Clin Exp Gastroenterol. 2016 Apr 4;9:71-82.
  2. Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther. 2015 Nov 6;6(4):145-55.