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Achalasia
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
6.
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.
31.
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.
36.
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.
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