Achalasia: Definition, Causes, Symptoms, Diagnosis and Treatment

It is a rare disorder of the esophagus, the tube that carries food from the throat to the stomach.

It is characterized by enlargement of the esophagus, impaired ability to push food into the stomach (peristalsis), and lack of muscle relaxation in the form of a ring in the lower part of the esophagus, the lower esophageal sphincter.

The job of the esophagus is to move food from the mouth to the stomach. When you have achalasia, this process occurs very slowly or does not occur at all.

As a result of this, the food returns to the esophagus and causes many unpleasant side effects, such as regurgitation and chest pain.

Achalasia is an esophageal motility disorder , which means there is a problem with the muscles and nerves responsible for moving food along your digestive tract.

When you have achalasia, one of these two things is happening:

  1. You can not coordinate muscle activity to move food and fluids from your esophagus to your stomach.
  2. The valve at the end of your esophagus (lower esophageal valve) does not open fully or does not open enough to allow food to empty into the stomach.

Causes

Some studies show that damage to nerve cells in your involuntary nervous system is responsible for the disease.

This damage causes an autoimmune response. The cells of your body attack the muscular layers of your esophagus, which slowly deteriorates the tissue.

Other theories on causality suggest that an infection, heredity or the presence of an abnormality in the immune system cause damage to the esophagus.

Achalasia has its effects on the muscles and nerves of the esophagus, however, it is thought that the effects on the nerves are more important.

When achalasia is started, some inflammations of the muscles of the lower esophagus are observed very close to the nerves.

When the disease progresses, the nerves usually degenerate, especially those that cause the esophageal sphincter to relax.

As the disease progresses, the cells that make up the muscles begin to degenerate, this due to the damage to the nerves.

These changes result in that the lower sphincter can not relax and the muscle in the esophageal body can not execute the peristaltic waves.

When the disease progresses, the body of the esophagus stretches and enlarges, dilating.

Symptoms of achalasia

Achalasia is a persistent problem, which means you experience symptoms all the time for months or even years.

Symptoms commonly occur during or after a meal and may include:

  • Difficulty or discomfort during swallowing ( dysphagia ).
  • Heartburn.
  • Sensation that food is passing very slowly through the esophagus.
  • Spasm type chest pain that comes and goes.
  • Discomfort in the chest due to esophageal dilation and food retention.
  • Sudden regurgitation of undigested food and saliva.
  • Spend a long time to finish a meal because it moves through the esophagus very slowly.
  • Weight loss due to reduced food intake.

Not all people experience all these symptoms, but most people who have achalasia experience difficulty swallowing.

Achalasia is a progressive disease, so your symptoms will get worse over time.

Diagnosis

The diagnosis of achalasia is often made on the basis of medical history.

Patients generally report an advance or worsening in swallowing (dysphagia) for both solid and liquid foods over a long period of time from many months to years.

Regurgitation of food, chest pain or weight loss is observed.

Rarely, the first symptom that occurs is aspiration pneumonia .

This delay in diagnosis is unfortunate since early treatment, before dilation of the esophagus occurs, can prevent esophageal dilation and possible complications.

Dysphagia, in achalasia, usually occurs with solid foods and liquids, but in esophageal stenosis and cancer, dysphagia occurs only with solid foods, and is only difficult with fluids, with progression of the stenosis.

All aspects of the condition should be examined using techniques such as:

X-ray studies

The diagnosis of achalasia is usually made by an X-ray study, in which video films are taken of the esophagus after ingesting the barium.

The barium fills the esophagus and you can see the emptying of the barium in the stomach.

In the case of achalasia, this study shows a dilated esophagus , with a narrowing of the lower end.

Esophageal manometry

Esophageal manometry specifically shows the abnormalities of muscle function, which are very common in achalasia, that is, the failure of the esophageal body muscle contracts when swallowing and the lower esophageal sphincter relaxes.

In a patient suffering from achalasia, the peristaltic waves are not observed in the lower half of the esophagus, and the pressure within the contracted esophageal sphincter does not relax with swallowing.

Endoscopy

Endoscopy is a useful procedure in the diagnosis of achalasia. In this procedure, a flexible fiber optic tube with a camera and a light at its end is introduced.

This camera provides a direct visualization inside the esophagus.

The first endoscopic findings of achalasia is the resistance that opposes the esophagus as the endoscope passes into the stomach, caused by a high pressure that exists in the lower esophageal sphincter.

With the evolution of the disease, endoscopy can reveal a dilated esophagus and deficiency and lack of peristaltic waves.

Endoscopy excludes the presence of esophageal cancer, ulcers, inflammation and infections.

You can also take a tissue sample (biopsy) and examine it under a microscope.

There are two conditions that can mimic achalasia: esophageal cancer and Chagas disease.

The disease of Chagas disease is an infection caused by the parasite, Trypanosoma cruzi, which mainly occurs in Central and South America.

Treatment for achalasia

The goals for achalasia treatments include:

  1. Help the lower esophageal valve open properly.
  2. Improve the ability of the esophagus to empty completely.

The treatment may include:

Botulinum toxin injections: injecting very small amounts of Botox into the muscles of the esophagus, helps to relax, allowing food to pass easily.

The treatment is done through an endoscopic injection of Botox in the lower sphincter, it is a fast, non-surgical treatment and does not require hospitalization.

The treatment is safe, although its effects on the sphincter often last only months, and additional injections with the toxin may be needed.

This procedure is a good option for patients of advanced age or who have a high risk in surgery, such as patients with severe heart or lung conditions.

This also allows those patients who have lost a lot of weight, eat improving their nutritional status before performing the “permanent” treatment with surgery. Reducing postoperative complications

Pneumatic dilatation: with an endoscope, a balloon is placed in the opening of the lower esophageal valve and expands. This loosens the muscles and widens the opening of your esophagus to allow food to pass through. The lower esophageal sphincter can also be treated directly by forced dilation.

Dilation of the lower esophageal sphincter is done by introducing a tube with a balloon at the end, this is placed with the help of X-rays. The goal is to stretch, actually, tear, the sphincter. If the dilation is not successful, the sphincter can still be treated surgically.

The complication of dilation is the rupture of the esophagus. 50% of the ruptures can be healed without surgery, patients who do not require surgery should be closely monitored and treated with antibiotics. Surgery can also repair the rupture, treat achalasia permanently with esophagomyotomy.

Oral endoscopic myotomy: this innovative and minimally invasive procedure helps open the esophagus and leaves no scars. The surgery is performed through an abdominal incision with a laparoscopy . This laparoscopic approach is used with uncomplicated achalasia.

Diet: There is no specific diet to treat achalasia, although alterations in diet are often made by patients as they learn which foods seem to pass most easily.

In general, more liquid foods pass more easily, and patients sometimes drink more water with their meals.

At the beginning of the progression of the disease, they may find that carbonated liquids help the food pass through, probably due to the increased intra-esophageal pressure caused by carbonation that “pushes” food through the sphincter.

If the weight loss is considerable, the food should be supplemented with a complete dietary liquid supplement, that is, containing all the necessary nutrients to prevent malnutrition.

Oral medications : oral medications may only provide relief short of the symptoms of achalasia, also presenting the disadvantage that many patients experience side effects with the use of medications.