This document discusses achalasia cardia. It begins with learning objectives about the surgical anatomy of the esophagus, physiology of swallowing, and tests for esophageal motility disorders. It then provides details on the anatomy, function, and physiology of the esophagus. It discusses diagnostic tests for achalasia like esophageal manometry and classifications of motility disorders. It introduces achalasia cardia, describing its pathogenesis, clinical presentation, investigations including barium swallow and manometry, and conservative treatments like pneumatic dilation and botulinum toxin injection.
Congenital anomalies of esophagus-Tracheoesophageal fistula, Esophageal atresia, esophageal stenosis, esophageal duplication cyst, esophageal webs or rings,, diverticulum of esophagus and congenital short esophagus
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Dysphagia is an important problem in surgical patients. I have discussed Introduction, Zenker's diverticulum, GERD, Achalasia Cardia and Carcinoma Esophagus. If you watch all these videos together, i assure you that you will become confident in managing a case of dysphagia.
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Abdominal xray - imaging and interpretation ArushiGupta119
everythng about abdominal radiograph is discussed from views to obstruction to foreign body.
definetly u r not going to get bored
read and share with your peers.
Congenital anomalies of esophagus-Tracheoesophageal fistula, Esophageal atresia, esophageal stenosis, esophageal duplication cyst, esophageal webs or rings,, diverticulum of esophagus and congenital short esophagus
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Dysphagia is an important problem in surgical patients. I have discussed Introduction, Zenker's diverticulum, GERD, Achalasia Cardia and Carcinoma Esophagus. If you watch all these videos together, i assure you that you will become confident in managing a case of dysphagia.
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Abdominal xray - imaging and interpretation ArushiGupta119
everythng about abdominal radiograph is discussed from views to obstruction to foreign body.
definetly u r not going to get bored
read and share with your peers.
Intestinal obstruction is the mechanical impairment which is partial or complete blockage of the bowel that results in the failure of the passage of intestinal content through the intestine.
A young girl presented in an OPD with chief complaints of swelling over right side of jaw x2months associated with pain ..FNAC done ...odontogenic evaluation done ..diagnosed with tubercular lymphadenitis
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Biomedical waste is very important to every person involved in the medical field and for normal lay person too. Without it's knowledge any treatment is incomplete.
it contains all the details about carcinoma of pancreas and it includes all relevant details in context to it from standard text books and internet sources .
no financial conflict involved .
pancreatic injury is very common in case of road traffic accident and it needs to be evaluated promptly and decision to be taken as early aas possible .this presentation will give an overview of pancreatic injury management.
Detailed information on assessing the trauma patients with time dependent principle management and selection between early total care and damage control surgery.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...
Achalasia cardia
1. Achalasia cardia
Target audience – Residents
Date- 10.9.2021
Moderator – Dr A. K.Srivastava
Professor
Speaker – Dr Pooja Pandey
PGJR2
Department of general surgery
MIMS, Barabanki
10/9/2021 1
2. Achalasia cardia
Learning objectives
• Surgical anatomy of esophagus
• Physiology of esophagus –Swallowing
• Physiologic reflux
• Test for the esophageal motility
• Classification of esophageal motility disorder
• Introduction on Achalasia cardia
• Clinical presentation
• How to diagnose
• Treatment
10/9/2021 2
3. Achalasia cardia
• Surgical anatomy
• 25-30 cm long .
• Posterior mediastinum.
• Pharynx to the cardia of the stomach .
• Musculature :- striated transitional zone smooth muscle
10/9/2021 3
10. Achalasia cardia
•Function
• Primary function – transport material from pharynx to the stomach .
• Secondary function – constrain the amount of air that is swallowed
and the amount of material that is refluxed .
• N.B- Transport of food bolus from mouth through esophagus into
the stomach begins with swallowing -postrelaxation contraction of
LES (In transit- co-ordinated peristaltic contraction )
10/9/2021 10
16. Achalasia cardia
Physiology
•Swallowing
•Esophageal phase
Primary Secondary Tertiary
*Progressive
*2-4cm/sec
*Generate
intraluminal
pressure-40-
80mmHg
*Reach LES-9sec
**Progressive
**Abdominal
distension or
Irritation of the
esophagus rather
than voluntary
swallowing .
***Non progressive
***Non peristaltic
***Monophasic or
multiphasic
***Occur after
voluntary
swallowing or
spontaneous
between swallows
throughout the
esophagus .
***Uncordinated
contraction of the
smooth muscle –
esophageal spasm
10/9/2021 16
18. Achalasia cardia
Physiology
•Physiologic reflux
•More common when awake and in the upright position than
during sleep in the supine position.
•The LES has intrinsic myogenic tone, which is modulated by
neural and hormonal mechanisms.
• Α-adrenergic neurotransmitters or β-blockers stimulate the
les, and α-blockers and β-stimulants decrease its pressure
10/9/2021 18
19. Achalasia cardia
Physiology
• Physiologic reflux
• The hormones gastrin and motilin have been shown to increase LES
pressure; and cholecystokinin, estrogen, glucagon, progesterone,
somatostatin, and secretin decrease LES pressure.
• The peptides bombesin, l-enkephalin, and substance P increase LES
pressure; and calcitonin generated peptide, gastric inhibitory peptide,
neuropeptide Y, and vasoactive intestinal polypeptide decrease LES
pressure
10/9/2021 19
20. Achalasia cardia
Physiology
• Physiologic reflux
• Pharmacologic agents such as antacids, cholinergics, agonists,
domperidone, metoclopramide, and prostaglandin F2 are known to
increase LES pressure; and anticholinergics, barbiturates, calcium
channel blockers, caffeine, diazepam, dopamine, meperidine,
prostaglandin E1 and E2, and theophylline decrease LES pressure.
• Peppermint, chocolate, coffee, ethanol, and fat are all associated
with decreased les pressure and may be responsible for esophageal
symptoms after a sumptuous meal.
10/9/2021 20
21. Achalasia cardia
Assessment of esophageal function
•(a) Tests to detect structural abnormalities of the esophagus;
•(b) Tests to detect functional abnormalities of the esophagus;
•(c) Tests to detect increased esophageal exposure to gastric
juice; and
•(d) Tests of duodenogastric function as they relate to
esophageal disease.
10/9/2021 21
22. Achalasia cardia
Esophageal motility study (EMS)
• Indication
• Motor abnormality of the esophagus –on the basis of complaints of
dysphagia, odynophagia, or noncardiac chest pain.
• Barium swallow or endoscopy unclear about structural
abnormality.
• To confirm the diagnosis of specific primary esophageal motility
disorders (i.e. Achalasia, diffuse esophageal spasm [DES],
nutcracker esophagus, and hypertensive LES).
10/9/2021 22
23. Achalasia cardia
Esophageal motility study (EMS)
• Indication
• Identifies nonspecific esophageal motility abnormalities and motility
disorders secondary to systemic disease such as scleroderma,
dermatomyositis, polymyositis, or mixed connective tissue disease.
• Symptomatic GERD , manometry of the esophageal body can
identify a mechanically defective les and evaluate the adequacy of
esophageal peristalsis and contraction amplitude.
• Preoperative evaluation of patients before antireflux surgery,
10/9/2021 23
24. Achalasia cardia
•Esophageal motility
A. Grade I flap valve appearance. Note the ridge of tissue that is closely approximated to the shaft of the
retroflexed endoscope. It extends 3 to 4 cm along the lesser curve.
10/9/2021 24
25. Achalasia cardia
•Esophageal motility
B. Grade II flap valve appearance. The ridge is slightly less well defined than in grade I and it
opens rarely with respiration and closes promptly.
10/9/2021 25
26. Achalasia cardia
•Esophageal motility
C. Grade III flap valve appearance. The ridge is barely present, and there is often failure
to close around the endoscope. It is nearly always accompanied by a hiatal hernia
10/9/2021 26
27. Achalasia cardia
•Esophageal motility
D. Grade IV flap valve appearance. There is no muscular ridge at all. The gastroesophageal valve stays open all
the time, and squamous epithelium can often be seen from the retroflexed position. A hiatal hernia is always
present.
10/9/2021 27
29. Achalasia cardia
EMS
•The pressure profile is repeated with
Each of the five radially oriented
Transducers-
•The average values for sphincter pressure
•Above gastric baseline,
•Overall sphincter length,
•And abdominal length
of the sphincter
are calculated.
10/9/2021 29
30. Achalasia cardia
•A mechanically defective sphincter is identified by having
one or more of the following characteristics:
• An average LES pressure of <6 mmHg
•An average length exposed to the positive-pressure
environment in the abdomen of 1 cm or less, and/or
•An average overall sphincter length of 2 cm or less.
10/9/2021 30
36. Achalasia cardia
•Esophageal Transit Scintigraphy.
•The esophageal transit of a 10-mL water bolus containing
technetium-99m (99mTc) sulfur colloid can be recorded with
a gamma camera.
• Using this technique, delayed bolus transit has been shown
in patients with a variety of esophageal motor disorders,
including achalasia, scleroderma, DES, and nutcracker
esophagus.
10/9/2021 36
37. Achalasia cardia
•Video- and Cineradiography
•Computerized capture of videofluoroscopic images and
manometric tracings is now available and is referred to as
manofluorography.
• Manofluorographic studies allow precise correlation of the
anatomic events, such as opening of the upper esophageal
sphincter, with manometric observations, such as sphincter
relaxation
10/9/2021 37
39. Achalasia cardia
Chicago classification of esophageal motility
10/9/2021 39
Type I (classic) achalasia: Impaired LES relaxation, absent peristalsis,
and normal esophageal pressure.
• Type II achalasia: Impaired LES relaxation, absent peristalsis, and
increased panesophageal pressure.
• Type III (spastic) achalasia: Impaired LES relaxation, absent
peristalsis, and distal esophageal spastic contractions.
41. Achalasia cardia
•Introduction
•Failure to relax.
•Primary motility disorder of the esophagus is achalasia.
•*Incidence of 1 per 100,000 population per year worldwide.
•*Prevalence – 9-10 per 100,000 people .
10/9/2021 41
*Maingot’s abdominal operation 13th edition pg no 972
42. Achalasia cardia
• Aetiopathogenesis
• Idiopathic- it occurs due to absence/degeneration of auerbach’s plexus
throughout the body of oesophagus, causing improper integration of
parasympathetic impulse .
• Acquired variety- in america, caused by trypanosoma cruzi which
destroys ganglion cells of auerbach’s plexus.(Chagas disease).
• Stress
• Emotional factors
• vitamin B1 deficiencies
10/9/2021 42
43. Achalasia cardia
Pathogenesis
• Neurogenic degeneration, which is either idiopathic or due to infection.
• This degeneration results in hypertension of the LES a failure of the
sphincter to relax on swallowing elevation of intraluminal esophageal
pressure esophageal dilatation, and a subsequent loss of progressive
peristalsis in the body of the esophagus.
• The esophageal dilatation results from the combination of a nonrelaxing
sphincter, which causes a functional retention of ingested material in the
esophagus, and elevation of intraluminal pressure from repetitive pharyngeal
air swallowing .
10/9/2021 43
44. Achalasia cardia
Clinical features
•Women around 20-40 yrs. of age are commonly affected
• Female: male::3:2
• Progressive Dysphagia-which is more for liquids than solid
food.
•Regurgitation and recurrent pneumonia are common
•Malnutrition and ill health
•Retrosternal discomfort - pain also radiates to interscapular
region
•Odynophagia and weight loss
10/9/2021 44
46. Achalasia cardia
Triad of Achalasia
• Staging I - Proximal dilatation <4cm
• Staging II- Dilatation b/w 4-7 cm
• Staging III- Dilatation >7cm
Dysphagia
Weight loss
Regurgitation
10/9/2021 46
47. Achalasia cardia
Investigations
Oesophagoscopy
dilated sac containing stagnant food and fluid due to stasis
LES is closed with air insufflation, rosette apperance
Oesophageal manometry- Aperistalsis in body of oesophagus
Ultrasound- detects subepithelial tumor infiltration in 2ndy
achalasia due to distal carcinoma
10/9/2021 47
48. Achalasia cardia
Oesophagoscopy
• FIGURE 22-1 Example of retained food and saliva at the time of upper endoscopy in a patient with an esophageal motility
disorder.
10/9/2021 48
49. Achalasia cardia
•Investigations
•Barium swallow- • bird beak appearance of lower
oesophagus, • Dilatation of proximal oesophagus • Absence
of fundic gas bubble • Sigmoid oesophagus
• X-ray chest- retrocardiac air fluid level lateral view
• Plain X-ray abdomen erect-fundic air bubble is absent due
to stasis of fluid in oesophagus
10/9/2021 49
52. Achalasia cardia
Conservative Treatment
•Forceful dilatation- using pneumatic balloon under
fluoroscopic control within LOS(300mmHg pressure applied
for 15 sec) .(S/E- eso.perf)
• Injection treatment- inj botulinum toxin is injected in LES
endoscopically ,blocks Ach release (Recurr-6months)
•Drugs- sublingual nifedipine gives short term relief
10/9/2021 52
53. Achalasia cardia
Conservative Treatment
•Nifedipine (10-30 mg administered 30-45 minutes before
meals).
• Isosorbide dinitrate (5-10 mg administered 10-15 minutes
before meals).
•Phosphodiesterase-5 inhibitors, such as sildenafil used to
treat patients with achalasia.
10/9/2021 53
54. Achalasia cardia
Surgical Treatment
•Open myotomy
•Four important principles:
•(a) Complete division of all circular and collar-sling muscle
fibers,
• (B) Adequate distal myotomy to reduce outflow resistance,
•(c) “Undermining” of the muscularis to allow wide
separation of the esophageal muscle, and
•(d) Prevention of postoperative reflux.
10/9/2021 54
55. Achalasia cardia
Treatment
• Heller’s cardiomyotomy (laparoscopic cardiomyotomy )
• surgical 7-10cm long incision made through lower
oesophageal end and carried over to stomach ,muscles are
cut till mucosa bulges out.
•Myotomy should be extended upto aortic arch and distally
up to stomach to 1-2cm below the junction.
10/9/2021 55
56. Achalasia cardia
• Heller’s cardiomyotomy
• A myotomy through all muscle layers is performed, extending
distally over the stomach to 1 to 2 cm below the junction, and
proximally on the esophagus for 4 to 5 cm.
• The cardia is reconstructed by suturing the tongue of gastric fundus
to the margins of the myotomy to prevent rehealing of the myotomy
site and to provide reflux protection in the area of the divided
sphincter.
• If an extensive dissection of the cardia has been done, a more
formal Belsey repair is performed.
10/9/2021 56
57. Achalasia cardia
• Heller’s cardiomyotomy
• The tongue of gastric fundus is allowed to retract into the abdomen.
• Traditionally, nasogastric drainage is maintained for 6 days to
prevent distention of the stomach during healing.
• An oral diet is resumed on the seventh day, after a barium swallow
study shows unobstructed passage of the bolus into the stomach
without extravasation.
10/9/2021 57
58. Achalasia cardia
•Modified Heller’s cardiomyotomy
•Left thoracotomy incision in the sixth intercostal space along
the upper border of the seventh rib.
10/9/2021 58
60. Achalasia cardia
Recent Advances
Peroral endoscopic myotomy (POEM)
•First described in 2010 by Inoue et al
•Allows a long myotomy to be performed from the lumen of
the esophagus with an endoscope.
•Type 3 achalasia (vigorous achalasia)
10/9/2021 60
61. Achalasia cardia
• Peroral endoscopic myotomy (POEM)
• Opening the esophageal mucosa 10 cm above the lower esophageal
sphincter with a needle–knife electrosurgery device passed through
an endoscope.
• A long submucosal plane is developed with the endoscope, down to
and below the les. The circular muscle of the LES, above and below
the gastroesophageal junction, is divided with endoscopic
electrosurgery.
• The submucosal entry site in the esophagus is then closed with
10/9/2021 61
62. Achalasia cardia
• Peroral endoscopic myotomy (POEM)
10/9/2021 62
A. After performing a submucosal injection, a mucosotomy is performed to gain access to the submucosal
space.
B. The submucosal tunnel is continued down the length of the esophagus and onto the stomach using
intermittent injections of methylene blue solution and electrocautery.
63. Achalasia cardia
• Peroral endoscopic myotomy (POEM)
10/9/2021 63
C. Following creation of the submucosal tunnel, the myotomy is performed. There are numerous
variations on this approach; however, the ultimate goal is to divide at minimum the circular fibers on the
esophagus and onto the stomach.
D. Following completed myotomy, the mucosotomy created at the beginning is then closed with either
clips or endoscopic sutures
64. Achalasia cardia
Complications
•The rate of esophageal squamous cell carcinoma is
increased in patients with achalasia compared to the
general population.
•There is also some concern for increased risk of
adenocarcinoma; however, this risk is significantly lower
than that for squamous cell carcinoma.
10/9/2021 64
65. References
• Schwartz’s principle of surgery vol-2 11th edition pg
no 1080-1086
• Sabiston text book of surgery vol-2 1st south asia
edition pg no 1010-1020
• Bailey & Love’s short practice of surgery 27th edition
pg no 1095-1099
• Maingot’s abdominal operation 13th edition (980-987)
10/9/2021 65
66. Questions
• Q1)What is achalasia ? Explain it’s pathophysiology?
• Q2) What is the prognosis of achalasia?When should a diagnosis of
achalasia be considered?
• Q3)What are the findings on the barium swallow that indicates achalasia
?
• Q4)What are the findings on the esophageal manometry that indicates
achalasia ?
• Q5)What is the goal of therapy for achalasia?
• Q6)What are the treatment options for achalasia?
• Q7)Expand the POEM and how it helps in treatment of achalasia ?
10/9/2021 66
Achalasia cardia – failure of relaxation of LES and aperistalsis of esophageal body with functional obstruction at esophagogastric junction and gradual dilation of esophagus. It occurs due to destruction of the nerves to LES as primary pathology and degeneration of neuromuscular function of esophagus is secondary pathology.
the transition
from pharynx to esophagus occurs at the lower border of
the sixth cervical vertebra. Topographically this corresponds
to the cricoid cartilage anteriorly and the palpable transverse
process of the sixth cervical vertebra laterally (Fig. 25-1). The
esophagus is firmly attached at its upper end to the cricoid
cartilage and at its lower end to the diaphragm; during swallowing,
the proximal points of fixation move craniad the distance
of one cervical vertebral body
The musculature of the esophagus can be divided into an
outer longitudinal and an inner circular layer. The upper 2 to
6 cm of the esophagus contains only striated muscle fibers.
From then on, smooth muscle fibers gradually become more
abundant. Most clinically significant esophageal motility disorders
involve only the smooth muscle in the lower two-thirds
of the esophagus. When a long surgical esophageal myotomy is
indicated, the incision needs to extend only this distance.
The longitudinal muscle fibers originate from a cricoesophageal
tendon arising from the dorsal upper edge of the
anteriorly located cricoid cartilage. The two bundles of muscle
diverge and meet in the midline on the posterior wall of
the esophagus about 3 cm below the cricoid (see Fig. 25-4).
From this point on, the entire circumference of the esophagus iscovered by a layer of longitudinal muscle fibers. This configuration
of the longitudinal muscle fibers around the most proximal
part of the esophagus leaves a V-shaped area in the posterior
wall covered only with circular muscle fibers. Contraction of
the longitudinal muscle fibers shortens the esophagus. The circular
muscle layer of the esophagus is thicker than the outer
longitudinal layer. In situ, the geometry of the circular muscle
is helical and makes the peristalsis of the esophagus assume a
wormlike drive, as opposed to segmental and sequential squeezing.
As a consequence, severe motor abnormalities of the esophagus
assume a corkscrew-like pattern on the barium swallow
radiogram.
The esophagus lies in the midline, with a deviation to the
left in the lower portion of the neck and upper portion of the
thorax, and returns to the midline in the midportion of the thorax
near the bifurcation of the trachea (Fig. 25-2). In the lower
portion of the thorax, the esophagus again deviates to the left
and anteriorly to pass through the diaphragmatic hiatus.
Three normal areas of esophageal narrowing are evident
on the barium esophagogram or during esophagoscopy. The
uppermost narrowing is located at the entrance into the esophagus
and is caused by the cricopharyngeal muscle. Its luminal
diameter is 1.5 cm, and it is the narrowest point of the esophagus.
The middle narrowing is due to an indentation of the anterior
and left lateral esophageal wall caused by the crossing of the
left main stem bronchus and aortic arch. The luminal diameter at
this point is 1.6 cm. The lowermost narrowing is at the hiatus of
the diaphragm and is caused by the gastroesophageal sphincter
mechanism. The luminal diameter at this point varies somewhat,
depending on the distention of the esophagus by the passage
of food, but has been measured at 1.6 to 1.9 cm. These normal
constrictions tend to hold up swallowed foreign objects, and the
overlying mucosa is subject to injury by swallowed corrosive
liquids due to their slow passage through these areas.
Cervical portion – Inferior thyroid artery from thyrocervical trunk.
Thoracic portion – Bronchial artery one from right side and two from left side(75%) , oesophageal artery from aorta
Abdominal portion – ascending branch of left gastric artery from celiac artery and inferior phrenic artery from abdominal aorta
On entering the wall it forms T shaped longitudinal network in the submucosal and muscular plexus hence mobilization from stomach to the aortic arch is possible without devascularisation -less chance for the ischaemia and necrosis.
Caution, however, should be exercised as to
the extent of esophageal mobilization in patients who have had
a previous thyroidectomy with ligation of the inferior thyroid
arteries proximal to the origin of the esophageal branches
Blood from the capillaries of the esophagus flows into
a submucosal venous plexus, and then into a periesophageal venous plexus from which the esophageal veins originate.
In the
cervical region, the esophageal veins empty into the inferior thyroid
vein; in the thoracic region, they empty into the bronchial,
azygos, or hemiazygos veins; and in the abdominal region,
they empty into the coronary vein (Fig. 25-9). The submucosal
venous networks of the esophagus and stomach are in continuity
with each other, and, in patients with portal venous obstruction,
this communication functions as a collateral pathway for portal
blood to enter the superior vena cava via the azygos vein.
Parasympathetic – vagus nerve
Few contribution from CN 9and 11
Damage to these nerves interferes not only
with the function of the vocal cords but also with the function
of the cricopharyngeal sphincter and the motility of the cervical
esophagus, predisposing the individual to pulmonary aspiration
on swallowing
Afferent visceral sensory pain fibers from the esophagus
end without synapse in the first four segments of the thoracic
spinal cord, using a combination of sympathetic and vagal pathways.
These pathways are also occupied by afferent visceral
sensory fibers from the heart; hence, both organs have similar
symptomatology.
In the submucosa
So dense than blood
Run in longitudinal than transverse
cervical – cephalad
In abdominal – caudad
In thoracic portion -the submucosal lymph plexus extends over a long distance in
a longitudinal direction before penetrating the muscle layer to
enter lymph vessels in the adventitia. As a consequence of this
nonsegmental lymph drainage, a primary tumor can extend for
a considerable length superiorly or inferiorly in the submucosal
plexus. Consequently, free tumor cells can follow the submucosal
lymphatic plexus in either direction for a long distance
before they pass through the muscularis and on into the regional
LNs.
The cervical esophagus has more direct segmental lymph
drainage into the regional nodes, and, as a result, lesions in this
portion of the esophagus have less submucosal extension and a
more regionalized lymphatic spread.
The cervical esophagus has more direct segmental lymph
drainage into the regional nodes, and, as a result, lesions in this
portion of the esophagus have less submucosal extension and a
more regionalized lymphatic spread.
The efferent lymphatics from the cervical esophagus drain
into the paratracheal and deep cervical LNs, and those from the
upper thoracic esophagus empty mainly into the paratracheal
LNs. Efferent lymphatics from the lower thoracic esophagus
drain into the subcarinal nodes and nodes in the inferior pulmonary
ligaments. The superior gastric nodes receive lymph not
only from the abdominal portion of the esophagus, but also from
the adjacent lower thoracic segment.
UES- 4-5cm in length , tone -60mmHg, preventing a steady flow of air into the esophagus
LES-24mmHg remains elevated just enough to prevent reflux
Cricopharyngeal sphincter- 60mmhg
Intrathoracic pressure :- -6mm hg
Intra abdominal -6mmhg
The peristaltic wave generates an occlusive pressure varying
from 30 to 120 mmHg (see Fig. 25-14). The wave rises
to a peak in 1 second, lasts at the peak for about 0.5 seconds,
and then subsides in about 1.5 seconds. The whole course of
the rise and fall of occlusive pressure may occupy one point in
the esophagus for 3 to 5 seconds.
Body of esophagus- 40-80mmHg
Duration -2.3-3.6 sec
LES not a true sphincter it’s a high pressure zone
First, reflux episodes occur in healthy volunteers
primarily during transient losses of the gastroesophageal
barrier, which may be due to a relaxation of the LES or intragastric
pressure overcoming sphincter pressure The average
frequency of these “unguarded moments” or of transient losses
of the gastroesophageal barrier is far less while asleep and in
the supine position than while awake and in the upright position.
Second, in the upright position,
there is a 12-mmHg pressure gradient between the resting, positive
intra-abdominal pressure measured in the stomach and the
most negative intrathoracic pressure measured in the esophagus
at midthoracic level. This gradient favors the flow of gastric
juice up into the thoracic esophagus when upright
This is due to the apposition
of the hydrostatic pressure of the abdomen to the abdominal
portion of the sphincter when supine. In the upright position,
the abdominal pressure surrounding the sphincter is negative
compared with atmospheric pressure, and, as expected, the
abdominal pressure gradually increases the more caudally it is
measured. This pressure gradient tends to move the gastric contents
toward the cardia and encourages the occurrence of reflux
into the esophagus when the individual is upright. In contrast,
in the supine position, the gastroesophageal pressure gradient
diminishes, and the abdominal hydrostatic pressure under the
diaphragm increases, causing an increase in sphincter pressure
and a more competent cardia.
ophageal
junction (GEJ), a rise in pressure above the gastric
baseline signals the beginning of the LES. The respiratory
inversion point is identified when the positive excursions that
occur in the abdominal cavity with breathing change to negative
deflections in the thorax. The respiratory inversion point serves
as a reference point at which the amplitude of LES pressure
and the length of the sphincter exposed to abdominal pressure
are measured. As the pressure-sensitive station is withdrawn
into the body of the esophagus, the upper border of the LES is
identified by the drop in pressure to the esophageal baseline.
From these measurements, the pressure, abdominal length, and
overall length of the sphincter are determined (Fig. 25-19).
This
“high-resolution manometry” is a variant of the conventional
manometry in which multiple, circumferential recording sites
are used, in essence creating a “map” of the esophagus and its
sphincters. High-resolution catheters contain 36 miniaturized
pressure sensors positioned every centimeter along the length
of the catheter. The vast amount of data generated by these
sensors is then processed and presented in traditional linear
plots or as a visually enhanced spatiotemporal video tracing that
is readily interpreted. The function of the esophageal body is
assessed with 10 to 15 wet swallows. Amplitude, duration, and
morphology of contractions following each swallow are visually
displayed (Fig. 25-21).
The position, length, and function of the lower esophageal
sphincter (LES) are demonstrated by a high-pressure zone
that should relax at the inception of swallowing and contract
after the water or solid bolus passes through the LES. Simultaneous
acquisition of data for the upper esophageal sphincter,
esophageal body, LES, and gastric pressure minimizes the
movement artifacts and study time associated with conventional
esophageal manometry. This technology significantly
enhances esophageal diagnostics, bringing it into the realm
of “image”-based studies. High-resolution manometry may
allow the identification of focal motor abnormalities previously
overlooked. It has enhanced the ability to predict bolus
propagation and increased sensitivity in the measurement of
pressure gradients.
In normal individuals, there is complete relaxation of the LES
during a swallow (to a measured level <8 mm Hg above gastric pressure).
However, in patients with achalasia, the LES relaxation during swallow may
be incomplete or absent all together. Additional manometric findings
consistent with achalasia include an elevated resting LES pressure of >45 mm
Hg and aperistalsis in the distal two-thirds of the esophagus
Total bolus transit time- time elapsed between bolus entry at 20cm above LES and bolus exit at 5cm above LES .
Normal liquid- 0.35-1.54sec
Pasty food -0.39-1.05sec
Solid-1sec – 12.8sec.
INTEGRATED RELAXATION PRESSURE- is the esophageal pressure topography metric used to know adequacy of esophagogastric junction ,
DISTAL CONTRACTILE INTEGRAL- vigor of contraction .product of amplitude,duration and length of the contraction between proximal and distal
India – incidence- 0.4-1.1 in 1lakh
Prevalence- 7.9-12.6 per 1lakh (research gate epidemiology and demographics )
There is no cure for achalasia; rather, treatment is aimed at palliating the
symptoms that patients experience. Therapies are directed at reducing the
contractility in the LES, thus allowing for adequate esophageal emptying.
Overall, the goal is early diagnosis and therapy to prevent late complications
while preserving esophageal function.
When evaluating the different subtypes, it has been found that type II
patients were significantly more likely to respond to any therapy (Botox,
71%; pneumatic dilation, 91%; or Heller myotomy, 100%) than type I (56%
overall) or type III patients (29% overall).
Although initial response to medical therapy is
approximately 50%, long-term success is limited by side effects, which
include headache, orthostatic hypotension, and edema.
Sidenafil They have been found to inhibit the contractile activity of the esophageal musculature in patients with achalasia,resulting in decreased LES tone
There is no cure for achalasia; rather, treatment is aimed at palliating the
symptoms that patients experience. Therapies are directed at reducing the
contractility in the LES, thus allowing for adequate esophageal emptying.
Overall, the goal is early diagnosis and therapy to prevent late complications
while preserving esophageal function.
Belsey mark IV Fundoplication is performed via left posterolateral thoracotomy .goal is to return the high pressure zone of the cardia otherwise known as the LES to its normal anatomical position below the diaphragm.
The antireflux mechanism in human beings is composed
of three components: a mechanically effective LES, efficient
esophageal clearance, and an adequately functioning gastric
reservoir. A defect of any one of these three components can
lead to increased esophageal exposure to gastric juice and the
development of mucosal injury.
Gastroesophageal reflux disease after surgical myotomy continues to be a
frequent problem, with rates approaching 30%.33 The addition of a surgical
fundoplication has been found in a blinded, randomized controlled trial to
reduce the rate of abnormal acid exposure in the esophagus from 47% to
9%.
While the results of POEM
are still accumulating, the procedure is attractive because it is
extremely minimally invasive, and can be done on an outpatient
basis. The major downside of POEM is that an effective antireflux
valve cannot be created, exposing the patient to a 40% to
50% risk of GERD post procedure.
Similar to surgical myotomy, gastroesophageal reflux
disease remains a common complication following POEM and is reported in
10% to 46% of patients
success rates
of over 90% at 1 year follow-up.