Uploaded bySantosh Narayankar
Achalasia cardia -epidemiology,clinical features,diagnosis,management,follw up
This document discusses Achalasia Cardia, a rare primary esophageal motor disorder of unknown etiology. It is defined by a lack of lower esophageal sphincter relaxation and esophageal peristalsis. Patients present with dysphagia, chest pain, and weight loss. Diagnosis involves high resolution manometry, barium swallow, endoscopy and CT or MRI. Treatment aims to reduce LES pressure and includes pharmacologic agents, botulinum toxin injection, pneumatic dilation, Heller's myotomy, and newer techniques like POEM. Management goals are to relieve symptoms and prevent complications through reducing esophageal stasis.
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Achalasia cardia -epidemiology,clinical features,diagnosis,management,follw up
- 1. Achalasia Cardia Presented By-DrSantosh M Narayankar
- 2. • Rare • Primaryoesophageal motor disorder • Unknown aetiology • Complex pathophysiology
- 3. Definition • Manometrically byinsufficient relaxation of the lower esophageal sphincter (LES) and loss of esophageal peristalsis • Radiographically by aperistalsis, esophageal dilation, with minimal LES opening, “ bird-beak ” appearance, poor emptying of barium. • Endoscopically by dilated esophagus with retained saliva, liquid, and undigested food particles in the absence of mucosal stricturing or tumor
- 4. Epidemiology Incidence is about1 per 100000 Male = Female Presents between age 25 and 60. Prevalence greatly exceeds its incidence Prevalence estimates range from 7.1 to 13.4 per 100,000 . Familial clustering of raise the possibility of genetic predisposition. Has been reported in monozygotic twins,siblings and children of affected parents.
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- 7. Proposed Patterns ofNeuronal Function (Postganglionic and Vagal) Among Achalasia Subgroups
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- 10. •Solids> liquids •Gradual onset over2yrs •Fluctuatesand eventually plateaus Dysphagia
- 11. •10% patients, •May bepresenting complaint, •Stridor and airway compramise Bronchopulmonary complications
- 12. •No acid reflex •Fermentation ofretained food by bacteria Heart Burn
- 13. • Due tospasm ?longitudinal muscle, • Not relived by treatment • spontaneous resolution Chest pain
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- 22. Differential Diagnosis Distal EsophagealSpasm Chaga’s Disease Pseudoachalasia Post Surgical
- 23. • Trypanosoma cruzi •Reduvid bug • Chronic phase over 20yrs,50% first detetction,90% dilatation • Megarectum colon ureter duodenum Chagas’ disease
- 24. • Occurs in5% pts manometricaly diagnosed achalasia Pseudoachalasia • Suspect when Age >50yrs • Abrupt &recent onset <1year • Early weight loss>7kg,resistance on endoscopy. • Adenocarcinoma of EGJ >50% cases • EUS/CT chest
- 25. •Fundoplication •Adjustable gastric bands • Difficultto asses Post surgical
- 26. Management In practical terms,this amounts to reducing LES pressure so that gravity promotes esophageal emptying. Treatment is directed at compensating for the poor esophageal emptying and preventing complications. Underlying neuropathology of achalasia cannot be corrected
- 27. Modalities Pharmacologic Botox injection Forceful dilatation-Pneumatic SurgicalMyotomy-Hellers POEM SEMS Esophagectomy
- 28. Pharmacologic • Amyl nitrate,NTG,Theophylline,B2 agonistsOthers •5-10mg • Reduces LES pressure by 66%, • Headache Isosorbide dinitrate • 30-40mg/day sublingual • Flushing,dizziness,edema,headcheNifidipine • 50mg • Side effectsSildenafil
- 29. Botulinum Injection • Intrasphincteric,4quadrants • 80 units • Decreases LES pressure by 33% • Improves dysphagia in 66% pts over 6 month period • chest discomfort and rash • Pts not fit for definitive treatment Botox injection
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- 31. • Long cylindricalnon compliant balloon • Sizees 3,3.5,4 cm • Positioned across LES fluroscopicaly • Esophageal perforation(1%) • Efficacy 32-98% Rigiflex Dilator
- 33. Surgical Myotomy Hellers myotomy1913 Anterior myotomy Lap > Thoracotomy Excellent results 62-100% Persistent dysphagia in <10% patients Overall mortality 2% Reflux disease managed by PPI Toupet/Dor – Lap myotomy+partial fundoplication
- 35. •Based on NOTES •90 %efficacy •Comparable to lap myotomy POEM
- 42. Other Modality • SEMS •Esophagectomy
- 46. Patient follow up •Assessment of symptom relief • Barium swallow • Endoscopy not recommended for cancer screening
- 47. Eckardt symptom scoring andstaging
- 48. Risk of cancer Squamouscell carcinoma Stasis hypothesis 0.15% risk annual Screening not required, can be done after 15years (ASGE) Dilated sigmoid esophagus
- 49. Take Home Message •Rare disease • Complex pathophysiology • Dysphagia main symptom • HRM for diagnosis • Endoscopy to rule out pseudoachalasia • Treatment –PD,LHM,POEM according to achalasia type
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