Name
ACHALASIA CARDIA
DESCRIPTION
DETAIL
D.D. - * DIFFUSE ESOPHAGEAL SPASM * CHAGAS DISEASEOTHER TESTS - * MECHOLYL TEST * CHOLECYSTOKININ (CCK) TEST. * X-RAY ABDOMEN - ABSENT GASTRIC GAS BUBBLE * BARIUM SWALLOW - NORMAL SEQUENTIAL PARISTALSIS IS REPLACED BY UNCOORDINATED SIMULTANEOUS CONTRACTIONS.
TYPENOTES
Medical Care: The goal of therapy for achalasia is to relieve symptoms by eliminating the outflow resistance caused by the hypertensive and nonrelaxing LES. Once the obstruction is relieved, the food bolus can travel through the aperistaltic body of the esophagus by gravity. " Calcium channel blockers and nitrates are used to decrease LES pressure. o Approximately 10% of patients benefit from this treatment. o This treatment is used primarily in elderly patients who have contraindications to either pneumatic dilatation or surgery. " Endoscopic treatment includes an intrasphincteric injection of botulinum toxin to block the release of acetylcholine at the level of the LES, thereby restoring the balance between excitatory and inhibitory neurotransmitters. o This treatment has limited value. Only 30% of patient's treated endoscopically still have relief of dysphagia 1 year after treatment. o This treatment can cause an inflammatory reaction at the level of the gastroesophageal junction, making a subsequent myotomy very difficult. o Use this treatment in elderly patients who are poor candidates for dilatation or surgery. " Pneumatic dilatation performed by a qualified gastroenterologist is the recommended treatment in those sporadic cases in which surgery is not appropriate. o A balloon is inflated at the level of the gastroesophageal junction to blindly rupture the muscle fibers while leaving the mucosa intact. o The success rate is 70-80%, and the perforation rate is approximately 5%. o If a perforation occurs, emergency surgery is needed to close the perforation and perform a myotomy. o As many as 50% of patients may require more than 1 dilatation. o The incidence of abnormal gastroesophageal reflux after the procedure is approximately 25%. " A laparoscopic Heller myotomy is considered by many to be the appropriate primary treatment of patients with achalasia (see Surgical Care). A Heller myotomy and a partial fundoplication performed from the chest (thoracoscopic) have a high incidence of gastroesophageal reflux. Surgical Care: Because of excellent results, a short hospital stay, and a fast recovery time, the primary treatment is considered by many to be a laparoscopic Heller myotomy and partial fundoplication. In the author's experience and in the experience of many authors, this treatment provides a fine balance in relieving symptoms of dysphagia by performing the myotomy and in preventing gastroesophageal reflux by adding a partial wrap. A prospective randomized study from Vanderbilt University has recently shown that a Heller myotomy plus a partial fundoplication was superior to a Heller myotomy alone in regard to the incidence of postoperative reflux. The same authors of this study have also shown that in patients with achalasia, adding a partial fundoplication not only is more effective in preventing postoperative reflux but also is more cost-effective at a time horizon of 10 years. However, the use of preoperative endoscopic therapy remains common but has resulted in intraoperative complications (eg, esophageal perforation) and postoperative complications and in a high failure rate. " Minimally invasive surgery for achalasia is carried out under general anesthesia with the use of 5 trocars. A controlled division of the muscle fibers (myotomy) of the lower esophagus (5 cm) and the proximal stomach (1.5 cm) is carried out, followed by a partial fundoplication to prevent reflux. " Patients remain hospitalized for 24-48 hours and return to regular activities in about 2 weeks. " The operation relieves symptoms in 85-95% of patients, and the incidence of postoperative reflux is 10-15%. " For patients in whom surgery fails, they may be treated with an endoscopic dilatation first. If this fails, a second operation (extending the previous myotomy onto the anterior gastric wall) can be attempted once the cause of failure has been identified with imaging studies. The last resort is to surgically remove the esophagus (ie, esophagectomy).
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
X-RAY CHEST P.A. VIEW( NORMAL ), X-RAY BARIUM SWALLOW, X-RAY CHEST LAT. VIEW, X-RAY ABDOMEN ERECT VIEW, ENDOSCOPY UPPER G.I., ESOPHAGEAL MANOMETRY