Achalasia cardia -epidemiology,clinical features,diagnosis,management,follw up
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achalasia cardia
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Achalasia cardia -epidemiology,clinical features,diagnosis,management,follw up
- 1. Achalasia Cardia Presented By-Dr Santosh M Narayankar
- 2. • Rare • Primary oesophageal motor disorder • Unknown aetiology • Complex pathophysiology
- 3. Definition • Manometrically by insufficient 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 about 1 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.
- 7. Proposed Patterns of Neuronal Function (Postganglionic and Vagal) Among Achalasia Subgroups
- 10. •Solids> liquids •Gradual onset over2yrs •Fluctuates and eventually plateaus Dysphagia
- 11. •10% patients, •May be presenting complaint, •Stridor and airway compramise Bronchopulmonary complications
- 12. •No acid reflex •Fermentation of retained food by bacteria Heart Burn
- 13. • Due to spasm ?longitudinal muscle, • Not relived by treatment • spontaneous resolution Chest pain
- 17. Barium studies
- 18. X-Ray chest
- 19. Endoscopy
- 20. Role Of EUS
- 21. CT Chest
- 22. Differential Diagnosis Distal Esophageal Spasm 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 in 5% 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 • Difficult to 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 Surgical Myotomy-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,4 quadrants • 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
- 31. • Long cylindrical non compliant balloon • Sizees 3,3.5,4 cm • Positioned across LES fluroscopicaly • Esophageal perforation(1%) • Efficacy 32-98% Rigiflex Dilator
- 33. Surgical Myotomy Hellers myotomy 1913 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 and staging
- 48. Risk of cancer Squamous cell 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
- 50. Thank You
- 51. History