What Is Achalasia

(Cardiospasm, aperistalsis of the esophagus, Megaesophagus)

Under a achalasia means a neurogenic motility disorder of the esophagus, characterized by decreased oesophageal peristalsis and a reduced relaxation of the LES during swallowing. Symptoms are a slowly developing dysphagia, usually for liquid and solid food and a regurgitation of undigested food particles. The clarification requires manometry, a barium swallow and endoscopy. The treatment consists of the dilation, the chemical denervation, the operative myotomy and peroalen endoscopic myotomy.

Under a achalasia means a neurogenic motility disorder of the esophagus, characterized by decreased oesophageal peristalsis and a reduced relaxation of the LES during swallowing. Symptoms are a slowly developing dysphagia, usually for liquid and solid food and a regurgitation of undigested food particles. The clarification requires manometry, a barium swallow and endoscopy. The treatment consists of the dilation, the chemical denervation, the operative myotomy and peroalen endoscopic myotomy.

(S. A. Overview Esophageal dysphagia.) Under an achalasia meant a neurogenic motility disorder of the esophagus, characterized by decreased oesophageal peristalsis and a reduced relaxation of the LES during swallowing. Symptoms are a slowly developing dysphagia, usually for liquid and solid food and a regurgitation of undigested food particles. The clarification requires manometry, a barium swallow and endoscopy. The treatment consists of the dilation, the chemical denervation, the operative myotomy and peroalen endoscopic myotomy. (See also the American College of Gastroenterology’s practice guidelines on the diagnosis and management of achalasia.) The cause of achalasia, a loss of ganglion cells in the myenteric plexus of the esophagus is assumed leading to denervation of Ösophagusmuskels. The etiology of denervation is unknown, but viral and autoimmune causes are suspected, and certain tumors can cause the image achalasia either by direct application or by paraneoplastic processes. The Chagas disease, which is characterized by damage to autonomic ganglia, may also lead to achalasia. Increased pressure in the LES leads to a narrowing and secondary dilatation of the esophagus. Retention of undigested food and fluid constituents in the esophagus is a common result. The symptoms and complaints achalasia can occur at any age, usually show the first symptoms between 20 and 60 years. The onset is insidious, sometimes with a long course of months and years. The main symptom is the dysphagia for solid and liquid food. A nocturnal regurgitation of undigested dietary components occurs in one third of patients and causes cough and aspiration. Although chest pain is a rarer symptom but can occur spontaneously or swallowing. generally observed a low to moderate weight loss; with significant weight loss, especially when it occurs in older people with rapidly developing symptoms of dysphagia, must be considered in a secondary achalasia as a result of a tumor of the gastroesophageal junction. Diagnosis Esophageal Occasionally barium swallow esophageal manometry is the preferred diagnostic test for achalasia. This test shows incomplete relaxation of the LES relaxation with integrated pressure ? 15 and 100% of failed peristalsis. The barium swallow is a complementary examination procedure is often performed during the initial phase of the investigation and can show an absence of progressive peristaltic contractions during swallowing. Normally, the esophagus – sometimes highly – expanded and concentrated in the lower part and beak similar rejuvenated. When a Esophagoscopy is carried out, there is a esophageal dilation, but no blocking lesion and a classic “Pop” is often felt when the esophagoscope reaches the stomach. In rare cases, these findings may result from a tumor; Endoscopic ultrasonography with biopsies can be considered to rule out cancer. The achalasia must diffenzialdiagnostisch from the distal stenosing carcinoma and be distinguished from a peptic stricture, v. a. in patients with systemic scleroderma in which the Speiseröhrenmanometrie may also give the image a aperistalsis. Scleroderma is usually by a Raynaud’s phenomenon and symptoms of gastroesophageal reflux disease (GERD) due to low or missing LES-pressure accompanied. A achalasia due to cancer at the gastroesophageal junction is diagnosed with a CT of the chest and the abdomen or with the endoscopic ultrasound with biopsy. Forecast lung aspiration and possible cancer determine the prognosis. Nocturnal regurgitation and coughing fits are suggestive of aspiration. Pulmonary complications due to aspiration are difficult to treat. Whether the incidence of esophageal cancer is increased in patients with achalasia, is controversial. Balloon dilatation treatment or surgical myotomy of the LES Occasionally peroral endoscopic myotomy Sometimes injection of botulinum toxin No therapeutic method results in the restoration of peristalsis. The treatment of achalasia is directed to a reduction in pressure on the LES. Balloon dilation of the LES and surgical myotomy appear similarly effective. In 2016, a randomized, controlled study has found with achalasia patients that had at the pneumatic balloon 5-year follow-up comparable efficacy with laparoscopic Heller myotomy (1). The most disturbing complication of this procedure is the perforation of the esophagus. The perforation rates vary according to the center, in the range of 0 to 14% for the pneumatic balloon and 0 to 4.6% for laparoscopic Heller myotomy (2). Other recent studies have shown that oral endoscopic myotomy has a good short-term results (3). Thus, the choice between these three methods is dependent on the person treated, and the particular type of achalasia. In patients for whom this treatment is not an option, can be tried by a chemical denervation of cholinergic nerves in the distal esophagus with a direct injection of botulinum toxin type A to treat in the LES. This measure clinical improvement occurs in 70-80% of patients, but the results usually stick to only 6-12 months. Reducing the pressure in the LES may increase the occurrence of GERD. The incidence varies depending on the nature of the treatment carried out. On average it is estimated that about 20% of patients have postprozedural GERD. Drugs such as nitrates (e.g., isosorbide dinitrate example 5-10 mg sublingual before meals), or calcium channel blocker (eg., Nifedipine 10-30 mg p.o. 30-45 min prior to a meal) may be attempted. These drugs have limited effective, but capable enough to reduce the pressure in the LES to extend the intervals between dilations. Treatment Notes 1. A Moonen, Annese V, Belman A, et al: Long-term results of the European trial achalasia: A multicentre randomized controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Intestine 65 (5): 732-739, 2016. doi: 10.1136 / gutjnl-2015-310602. 2. Lynch KL, Pandolfino JE, Howden CW, et al: Major complications of pneumatic dilation and Heller myotomy for achalasia: Single-center experience and systematic review of the literature. Am J Gastroenterol 107 (12): 1817-1825, 2012. doi: 10.1038 / ajg.2012.332. 3. Rentein DV, Fox K-H, Fockens P, et al: Peroral endoscopic myotomy for the treatment of achalasia: An international prospective multicenter study. Gastroenterology 145 (2): 272-273, doi 2013: 10.1053 / j.gastro.2013.04.057 Key points A virus- or autoimmune-associated loss of ganglion cells in the myenteric plexus of the esophagus reduces the oesophageal peristalsis and affects the relaxation of the lower esophageal sphincter (LES). Patients develop gradually dysphagia for both solid foods as well as liquids, and about a third vomit undigested food in the night. The esophageal manometry is the preferred test for achalasia and shows an increased integrated expansion pressure associated with 100% failed peristalsis. A barium swallow, the absence of progressive peristaltic contractions during swallowing and a significantly extended esophagus with beak-like constriction to the LES. No therapeutic method leads to the restoration of peristalsis. The treatment is directed at the LES to a reduction in pressure (and thus the obstruction). The treatment is usually a pneumatic balloon dilation or myotomy of the LES. More information Practice guidelines fromthe American College of Gastroenterology on the diagnosis and management of achalasia

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