Achalasia

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  • Achalasia is the result of a primary or secondary derangement of the myenteric plexus, the network of neurons involved in the coordination of GI motility..(MCQ)
  • The resulting dysphagia is due to three mechanisms:.(MCQ)
    • Nonperistalticcontrations
    • Incomplete relaxation of the LES after swallowing
    • Increased resting tone of the LES
  • Signs and symptoms
    • Dysphagia for both solids and liquids.(MCQ)
    • Regurgitation of food
    • Severe halitosis (due to the decomposition of stagnant food within theesophagus.(MCQ)
  • Diagnosis
    • Lateral upright chest x-ray (CXR) may reveal
      • a dilated esophagus.(MCQ)
      • presence of air–fluid levels in the posterior mediastinum..(MCQ)
    • Barium swallow will reveal the characteristic distal bird’s beak sign due to the collection of contrast material in the proximal dilated segment and the passage of a small amount of contrast through the narrowed LES..(MCQ)
    • Esophageal motility study will confirm .(MCQ)
      • nonperistaltic contractions
      • incomplete LES relaxation
      • increased LES tone.
    • Esophagoscopy is indicated to rule out mass lesions or strictures, and to obtain specimens for biopsy.
  • Treatment
    • Medical management:
      • Drugs that relax the LES such as nitrates or calcium channel blockers
    • Surgical management
      • Esophagomyotomywith fundoplication:
        • Esophagus is exposed via transthoracic (left thoracotomy), transabdominal, thorascopic, or laparoscopic technique.
        • The tunica muscularis of the esophagus is incised distally, with extension to the LES.
        • Complete division of the LES necessitates the addition of an antireflux procedure such as Nissen 360° fundoplication or partial fundoplication..(MCQ)
      • Endoscopic dilatation:
        • Lower success rate and a higher complication rate
        • Involves inserting a balloon or progressively larger sized dilators.(MCQ)
        • through the narrowed lumen, which causes tearing of the esophageal smooth muscle and decreases the competency of the LES.
      • Complications
        • Risk of squamous cell carcinoma is as high as 10% in patients with long-standing achalasia (15 to 25 years)..(MCQ)
        • Patients may also develop pulmonary complications such as .(MCQ)
          • aspiration pneumonia
          • bronchiectasis

asthma, due to reflux and aspiration

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