Achalasia

Presentation

  • Dysphagia for both solids and liquids
  • Retrosternal Pain
  • Regurgitation
  • Gradual weight loss
  • Assess risk factors that may suggest malignancy

Differentials

  • Oesophageal carcinoma
  • Oesophageal stricture.
  • Gastric cancer, possibly involving the lower oesophagus.
  • Gastro-oesophageal reflux

Radiological investigations

  • Upper GI endoscopy
    • Mucosa obscured by retained saliva with frothy appearance
  • Barium Swallow
    • Loss of peristalsis and delayed oesophageal emptying
    • Bird beak sign
    • Oesophageal dilatation
  • Manometry of the oesophagus
    • Incomplete relaxation of the lower oesophageal sphincter
    • Oesophageal aperistalsis

Management

First Line

Pharmacological

  • Calcium-channel blockers taken prior to meals
    • Nifedipine
    • Verapamil
    • Nitrates

Surgical

  • Pneumatic dilatation
    • Mechanical dilatation of the lower oesophageal sphincter using a balloon
    • Performed endoscopically

Complications

  • Aspiration pneumonia
  • Oesophageal perforation
  • Increases risk of GORD
  • Increases risk of oesophageal carcinoma

Prognosis

  • No known cure
  • Treatment is symptomatic - aims to improve oesophageal emptying and reducing symptoms of dysphagia
  • Perforation rate of up to 5% in pneumatic dilatation
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