Achalasia

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Esophagus anatomy and nomenclature based on two systems.

• Inability of LES to relax and loss of normal peristalsis

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

Barrium swallow showing birds beak appearance

• Esophageal Manometry

Aperistaltic contractions, increased intraesophageal pressure, and failure of relaxation of the lower esophageal sphincter.

Management

• Trial of antispasmodic for esophageal spasm
  • Nifedipine
• Surgical intervention
  • Balloon dilatation
  • Botulinum toxin injection
  • 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

See Also

• Ingested foreign body