Achalasia: Difference between revisions
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==Background== | ==Background== | ||
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]] | |||
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]] | |||
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]] | |||
*Inability of LES to relax and loss of normal peristalsis <ref>Krill JT, Naik RD, Vaezi MF. Clinical management of achalasia: current state | *Inability of LES to relax and loss of normal peristalsis <ref>Krill JT, Naik RD, Vaezi MF. Clinical management of achalasia: current state | ||
of the art. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831602/ Clin Exp Gastroenterol. 2016 Apr 4;9:71-82.]</ref> | of the art. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831602/ Clin Exp Gastroenterol. 2016 Apr 4;9:71-82.]</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
*Dysphagia | *[[Dysphagia]] | ||
*Regurgitation | *Regurgitation | ||
*[[Chest pain]] | *[[Chest pain]] | ||
**Esophageal spasm can | **Esophageal spasm can feel like tight, crushing retrosternal pain similar to ACS | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Ingested foreign body]] | *[[Ingested foreign body]] | ||
*Esophageal carcinoma - ''dysphagia predominantly for solid foods during initial stages'' | *Esophageal carcinoma - ''dysphagia predominantly for solid foods during initial stages'' | ||
*Reflux esophagitis - ''dysphagia results from inflammatory swelling or a fibrotic stricture'' | *Reflux [[esophagitis]] - ''dysphagia results from inflammatory swelling or a fibrotic stricture'' | ||
*Pseudoachalasia - ''underlying malignancy mimics achalasia'' | *Pseudoachalasia - ''underlying malignancy mimics achalasia'' | ||
*Connective tissue disorders - ''e.g. systemic sclerosis'' | *[[Connective tissue disorders]] - ''e.g. [[scleroderma|systemic sclerosis]]'' | ||
*Esophageal spasm - ''chest pain a predominant feature'' | *Esophageal spasm - ''chest pain a predominant feature'' | ||
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**Birds beak sign | **Birds beak sign | ||
[[File:Birds Beak.JPG|thumbnail|Barrium swallow showing birds beak appearance]] | [[File:Birds Beak.JPG|thumbnail|Barrium swallow showing birds beak appearance]] | ||
*Esophageal Manometry | *Esophageal Manometry | ||
[[File:Manometry.jpg|thumbnail|Aperistaltic contractions, increased intraesophageal pressure, and failure of relaxation of the lower esophageal sphincter.]] | [[File:Manometry.jpg|thumbnail|Aperistaltic contractions, increased intraesophageal pressure, and failure of relaxation of the lower esophageal sphincter.]] | ||
==Management== | ==Management== | ||
*Trial of antispasmodic for [[ | *Trial of antispasmodic for esophageal spasm | ||
**[[Nifedipine]] | |||
*Surgical intervention | *Surgical intervention | ||
** | **Balloon dilatation | ||
**Botulinum toxin injection <ref>Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635155/ 2015 Nov 6;6(4):145-55.]</ref> | **Botulinum toxin injection <ref>Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4635155/ 2015 Nov 6;6(4):145-55.]</ref> | ||
**Myomectomy | **Myomectomy | ||
Revision as of 22:33, 7 February 2024
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
- Esophageal Manometry
Management
- Trial of antispasmodic for esophageal spasm
- Surgical intervention
- Balloon 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
- ↑ Krill JT, Naik RD, Vaezi MF. Clinical management of achalasia: current state of the art. Clin Exp Gastroenterol. 2016 Apr 4;9:71-82.
- ↑ 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.