Esophagus is the swallowing tube that connects your mouth to the stomach. The food you swallow is moved by contraction called peristaltic movements into the stomach which is mediated by neuron plexuses situated in the wall of the esophagus. Achalasia cardia is a rare disorder caused due to the dysfunction of ganglion cells in the neuron plexus called the myenteric plexus situated in the wall of the esophagus.
This causes paralysis of the esophagus and dilatation of it resulting inability of the esophagus to squeeze food into the stomach. At the base of the esophagus, there is a ring-shaped muscle called the lower esophageal sphincter. This muscle is drawn tightly closed when you aren’t eating to prevent food and gastric juices from regurgitating up into the esophagus and causing damage. Achalasia cardia also causes absent relaxation of this lower esophageal sphincter which makes it harder to transfer food from the esophagus into the stomach.
This disease mainly affects genders and races equally and is a condition that occurs in adults. It’s most common for this condition to develop between the 20s and 50s of age.
Causes for Achalasia Cardia
- The causes of Achalasia are not identified and is called idiopathic disease.
- Genetic causes
- Some autoimmune diseases
- Infections
- Anorexia
- Spinal cord trauma
- Lymphoma
- Chagas disease
- Neurodegenerative disorders
- Stomach carcinomas
Clinical Features of Achalasia Cardia
- Difficulty in swallowing which is initially for fluids and later develops for solids as well.
- Pain during swallowing can be present in the early stages.
- Regurgitation of food into the mouth.
- Aspiration of food or overspilling to the wind tube especially at night during sleeping.
- Mild chest pain which comes in intermittent episodes.
- Dry mouth and dry eyes.
- Malnutrition
- Loss of weight.
- Pneumonia and respiratory tract infections can also occur due to aspiration.
Diagnosis of Achalasia Cardia
This disease remains undiagnosed for a long period as it is a rare condition. Initially, after the clinical assessment through the history and examination of the patient, the doctor will recommend imaging investigations to confirm the diagnosis.
- Upper GI endoscopy may show a tight lower esophageal sphincter and residual food content in the esophagus.
- Barium swallow study and X-ray imaging can also be used to confirm the diagnosis.
Management of Achalasia Cardia
Achalasia is not completely curable. The main goal of treatment is symptomatic management and prevention of complications. Surgical and medical methods of management can be identified.
Surgical Management
- Pneumatic dilatation is the commonest surgical procedure used, which includes the insertion of a balloon into the esophagus and expansion to widen the opening of the lower esophageal sphincter which is contracted due to the disease. The disadvantage of this procedure is it often requires to be repeated.
- Heller’s myotomy includes cutting the lower esophageal sphincter and upper part of the stomach while connecting them afterward. It has a very high success rate of more than 90%.
- Per-oral endoscopic myotomy in which a tube is passed through your mouth and a small incision is made the in the lower esophageal sphincter to open and loosen it. But this procedure also needs to be repeated over time.
- Injecting botulinum toxin into the lower esophageal sphincter through endoscopy is another method that causes temporary relaxation of the contracted sphincter.
Pharmacological Management
Muscle relaxers including calcium channel blockers such as nifedipine are used to relieve achalasia cardia symptoms transiently until the definitive surgical management is received. These drugs are not suitable for Long-term management.
Diet changes including the thickness and textures of foods and liquids may also help to improve swallowing difficulties.
References
- Bailey and Love’s Short Practice of Surgery- 27th Edition
- Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
- Oxford Handbook of Clinical Medicine – 10th Edition
- Browse’s Introduction to the Symptoms and Signs of Surgical Disease – 4th Edition – Norman L. Browse, John Black, Kevin G. Burnand and William E.G. Thomas
