Achalasia

Background
  • Inability of LES to relax and loss of normal peristalsis [1]

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
  • Surgical intervention
    • Balloon dilatation
    • Botulinum toxin injection [2]
    • 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

Disposition

See Also

References
  1. Krill JT, Naik RD, Vaezi MF. Clinical management of achalasia: current state of the art. Clin Exp Gastroenterol. 2016 Apr 4;9:71-82.
  2. Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther. 2015 Nov 6;6(4):145-55.
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