achalasia.pdf
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Achalasia is a condition caused by the loss of inhibitory ganglion cells in the esophagus, resulting in failure of the lower esophageal sphincter (LOS) to relax. This leads to difficulty swallowing food and liquid (dysphagia), chest pain, and regurgitation. Diagnosis involves endoscopy, barium radiology, and manometry showing an non-relaxing LOS and absent esophageal peristalsis. Treatment options include pneumatic dilatation of the LOS using a balloon, Heller's myotomy to cut the LOS muscle, botulinum toxin injection into the LOS, or temporary use of calcium channel blockers or nifedipine for relief
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1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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achalasia.pdf
- 2. Dr. Masrur Akbar Khan
- 3. Achalasia (Greek ) ‘Failure to relax’
- 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.
- 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)
- 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
- 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