Achalasia

WHAT IS AN OESOPHAGEAL MOTILITY DISORDER?

The oesophagus is a muscular tube that starts from the upper neck and goes till the stomach. The food and fluid is carried by oesophagus to the stomach by the movement known as peristalsis. Motility disorders occur when these peristaltic movements become discoordinated or weak which interrupt the passage of food from mouth to the stomach. Motility disorders cause difficulty in swallowing of food, regurgitation, and ,sometimes, a painful spasm-type pain.

WHAT IS ACHALASIA?

There are many types of oesophageal motility disorders; achalasia is one of its types. This disorder occurs because of the absence of contractions in the lower end of the oesophagus together with failure of the lower oesophageal sphincter to relax to allow food to pass into the stomach. There is a gradual difficulty in swallowing of food that start with solid food but later affect the swallowing of liquids too. This takes years to develop and some patients develop spasm-like chest pain. Regurgitation of food often occurs on lying flat. Patients adapt by eating slowly to allow food more time to enter the stomach. Weight loss often occur late in this condition as patients avoid eating.

WHAT CAUSES ACHALASIA?

In achalasia there is degeneration of nerve cells within the muscle layer of the oesophagus. The cause of this degeneration is currently unknown

HOW COMMON IS ACHALASIA, AND WHO GETS IT?

Achalasia is uncommon, occurring in one in 100,000 of the population per year. It affect both sexes equally. It is usually encountered in adults and only rarely in children. It does not run in families.

HOW DO I KNOW IF I HAVE ACHALASIA?

The main symptoms which a patient of achalasia may notice are difficulty in swallowing, regurgitation food in the mouth and stabbing pain in the chest. The first symptom which is noticed is difficulty in swallowing; later on regurgitation occurs. Pain is a very uncommon finding and is not always present in every case.

HOW PEOPLE ARE EVALUATED FOR POSSIBLE ACHALASIA?

Endoscopy
Endoscopy is done for the patients who feel difficulty in swallowing to exclude the possibility of cancer. Patient is sedated or simply anesthized to do the endoscopy, this procedure is done in outpatient basis. A small and flexible tube like telescope is passed through the mouth to the stomach via oesophagus, by this the specialist assesses the lining and muscular activity of oesophagus and stomach. Achalsia is suspected if there is a muscular constriction in the lower end of the oesophagus, changes in the lining of the oesophagus or residual food in the oesophagus.

Barium Swallow
Many patients may undergo a Barium swallow. This is an x-ray test of the oesophagus done while the patient swallow a liquid that is visible on x-ray.

Oesophageal Manometry
This is the best test for achalasia. It is done as an outpatient test with a small catheter that has built-in pressure sensors inserted through the nose into the oesophagus. The pressure trace recorded by the sensors is a very accurate test for achalasia.

WHAT TREATMENTS ARE AVAILABLE FOR ACHALASIA?

If not treated, achalsia worsen with time. Though there is no successful oral drug treatment, there are few effective modalities of treatment for achalsia.

Endoscopic Treatment

1. Pneumatic dilatation. This is done by passing a endoscope to the stomach where the sphincter is present (the constricted part), the endoscope has a balloon attached to its end, when the tube reaches the targeted position the balloon is inflated which breaks the muscles of sphincter forcefully and opens the area for passage of food. 75% of these treatments proves to be successful and gives the patient several years of satisfactory life without any problem in swallowing the food. But this procedure also has some risks. Each dilatation has a 3% chance of rupturing the oesophagus. If this occurs, then emergency surgery is needed to repair the oesophagus and surgically treat the achalasia.
2. Botulinum toxin i.e. Botox injection. Under the endoscopic guidance Botox is injected into the sphincter which paralyzes the muscles of sphincter and opens the inlet to the stomach, this relieves the patient of symptom but is only valid for a year. 60% of patients opt for this treatment.

Surgical Treatment

Surgery is recommended to many patients. During the operation the muscle sphincter at the lower end of the oesophagus is cut. This opens the valve between the oesophagus and the stomach. The operation is very successful and produces long lasting relief in 95% of patients. Traditionally the surgery was performed using the open technique which required a hospital stay of around one week. For the past two decades the operation is done via key-hole (laparoscopy) technique which result in a quick recover and a hospital stay of one or two days. . A fundoplication is often combined with the operation to reduce the chance of regurgitation and heartburn. Click here to read more about fundoplication.

It is important to note that it is not possible to treat achalasia completely and relief the patients of all the symptoms since the exact cause of the disorder is still not known. Many patients feel some residual symptoms even after successful treatment but they can enjoy a nearly normal lifestyle.