surgery

1. ACHALASIA CARDIA

2. Dr. Masrur Akbar Khan

3. Achalasia
(Greek )
‘Failure to relax’

4. PATHOLOGY AND AETIOLOGY

5. Loss of the inhibitory ganglion cells in the myenteric
(Auerbach’s) plexus

7. In South America a chronic infection by parasite
Trypanosoma cruzi with marked clinical similarities to
achalasia.

8. Achalasia
Dilated oesophagus contains few
ganglion cells
• Hirschsprung’s disease
– Dilated colon contains normal
ganglion cells proximal to a
constricted, aganglionic segment.

9. PHYSIOLOGICAL ABNORMALITIES

10. • Non-relaxing LOS
• Absent peristalsis
in the body of the
oesophagus.

11. • Uncoordinated contractions result in
– Pain
– Sense of food sticking.

12. • Oesophagus dilates and contractions
disappear
• Incomplete emptying by hydrostatic pressure
of its contents.

13. • Residual food and fluid.
• Absent gas bubble in stomach

14. • Megaoesophagus becomes tortuous
• Persistent retention oesophagitis due to
fermentation of food residues

15. • This accounts for increased incidence of malignancy
• Pre-malignant condition

16. Pseudoachalasia
• Achalasia-like disorder
• Produced by
adenocarcinoma of cardia
• Also other cancers outside
the oesophagus (bronchus,
pancreas)

17. CLINICAL FEATURES

18. • Dysphagia more for liquids than solids

19. • Chest Pain
• Regurgitation

20. • Nocturnal cough
• Recurrent aspiration

21. DIAGNOSIS

22. • ( Normal Cardia)

23. Endoscopic findings
• Tight cardia

24. • Food residue in
oesophagus.

25. Barium radiology
• Held-up in distal oesophagus
• Abnormal contractions in oesophageal body

26. • Tapering
stricture in
distal
oesophagus
(Bird’s beak)

27. • Absent fundic gas

28. Oesophageal manometry
• LOS not relaxed completely on swallowing
• No peristalsis
• Raised resting pressure in the oesophagus

29. TREATMENT

30. Pneumatic dilatation
• Stretching cardia with a balloon to disrupt
muscle and render it less competent.

32. • Perforation is the major complication.
• Forceful dilatation is curative in 75–85 per
cent of cases.

33. Heller’s myotomy
• Cutting muscle of lower oesophagus and
cardia.
• Major complication is gastrooesophageal
reflux

34. • Surgeons therefore add a partial anterior
fundoplication (Heller-Dor’s operation).

35. • The procedure is ideally suited to a minimal
access laparoscopic approach
• Successful in >90% cases
• May be used after failed dilatation.

37. Botulinum toxin
• Endoscopic injection
into LOS.
• Interferes with
cholinergic
excitatory neural
activity at LOS.

38. • Not permanent.
• Has to be repeated after a few months.
• Restricted to elderly patients with other
comorbidities.

39. Drugs
• Calcium channel antagonists have been used.
• Ineffective for long-term use.
• Sublingual nifedipine
– Useful for transient relief

40. Queries & Comments